Documentation
- Thread starter bdoss2006
- Start date
NomadicMedic
I know a guy who knows a guy.
- 12,226
- 7,010
- 113
Does your agency specify DCHART as the documentation method? If so, ask to see examples of what they consider appropriate documentation as specified by their billing company or QA specialist.
If this helps, here’s a breakout. https://emergencymed.arizona.edu/sites/default/files/ems-public/dacharte.pdf
I will also say that you can quickly document your way into a Medicare or Insurance denial of payment unless you are carefully documenting the PCR. Newer EMTs often don’t understand the rationale behind a BLS transport or don’t carefully parse the PMNC and document conflicting information. If your agency has specific documentation requirements for non emergency transports, you would be best served to have them explain the nuance of appropriate documentation to you, instead of relying on an anonymous forum.
If this helps, here’s a breakout. https://emergencymed.arizona.edu/sites/default/files/ems-public/dacharte.pdf
I will also say that you can quickly document your way into a Medicare or Insurance denial of payment unless you are carefully documenting the PCR. Newer EMTs often don’t understand the rationale behind a BLS transport or don’t carefully parse the PMNC and document conflicting information. If your agency has specific documentation requirements for non emergency transports, you would be best served to have them explain the nuance of appropriate documentation to you, instead of relying on an anonymous forum.
Last edited:
- 5,017
- 1,413
- 113
I'm with NomadicMedic on this. If you don't carefully pay attention to the Physician's Medical Necessity Certification, you very well could inadvertently chart something that results in an insurance/Medicare denial because what you charted might well conflict with the PMNC. I'll give you a strong hint: the PMNC states why the specific mode of transport is required and usually it also states that gurney/wheelchair transport is generally not covered. So, pay attention to why BLS or higher transport is required.
COVA2006
Forum Probie
- 14
- 6
- 3
Thanks for the info. I’m used to running 100% 911 calls & will be mostly inter-facility transfers. Not sure if I’ll like it.
- 5,017
- 1,413
- 113
One of the things I enjoy about running IFT calls (I'm a CCT-RN now) is that if I'm not too busy, I get a chance to read the paperwork. If I'm doing an IFT where the origin and destination are in the same system and therefore no transfer paperwork, I will usually ask for at least a copy of the physician's note and read that as it usually has at least some lab work, some basic background/history info if that's available, and some of the meds that have been ordered. Between that and what I would get in report from the sending RN (and sometimes the sending physician), I have a decent idea what I'm going to do and how busy I'm going to be during transport.
Some physicians will do near real-time charting so I'll even get some of the procedure notes and imaging results.
All told, having that info can be a good thing as I then get to learn more and more about how patients can present or actually be far more ill than they first appear.
If you do enough IFT transports and you get to know some of the local providers, you can be or get informal feedback on some of the cases you transport.
Some physicians will do near real-time charting so I'll even get some of the procedure notes and imaging results.
All told, having that info can be a good thing as I then get to learn more and more about how patients can present or actually be far more ill than they first appear.
If you do enough IFT transports and you get to know some of the local providers, you can be or get informal feedback on some of the cases you transport.