Improving Your Agency’s EMS Documentation


Improving Your Agency’s EMS Documentation

Now more than ever, documentation is being examined by payers using trained healthcare professionals. Since 2007, over $3.82 billion dollars has been recovered through audits and investigations. Although EMS represents a small fraction of this larger value, the government is looking to recoup every penny. The most effective way to ensure your agency is getting paid for all your services is through accurate EMS documentation.

Patient Care Report (PCR)

EMS documentation is a key component in the continuum of care.  Other healthcare professionals can make important decisions that affect patient health, based on the content of a PCR. Complete your PCR as soon as time permits after a call.

The role of a PCR includes:

  • Medical/QA Record
  • Legal/Compliance Documents
  • Basis for Reimbursement
  • Source of Data Collection

Fundamentals of a PCR include:

  • Demographics & Insurance
  • Accurately spelled name
  • Address
  • DOB
  • SSN
  • Copy of driver’s license
  • Copy of insurance card (front & back)
  • Hospital face sheet
  • Times
  • Dispatch
  • Enroute
  • At Scene
  • Time of Patient Contact
  • Depart Scene
  • At Destination
  • Available
  • Odometer
  • At scene
  • At destination
  • Remember to capture fractional
  • Multiple solutions available for tracking
  • Narrative
  • Main points of emphasis
  • The detail with which you write
  • The logic of how you write

How Documentation is Interpreted

Documentation is translated into ICD-10 codes, placed on claim forms, and submitted for payment. Each character within the ICD-1- Code adds a layer of detail, while specificity helps reveal the most appropriate codes.

Everyone at Cornerstone Adminisystems is a NAAC Certified Ambulance Coder.

Fundamentals of Good Documentation

Good documentation relies on details. We created a free downloadable Documentation Quick Reference Guide that outlines the necessary items that should be included in a PCR. This information includes:

Dispatch & Response

  • Dispatch
    • Was it 911 or equivalent?
    • If non-emergency, explain circumstances.
  • Response
    • Was response immediate?
  • Nature of Call
    • Explain if call was an emergency or non-emergency.
  • Class
    • Class I, II, III, IV (definitions can vary)
  • Chief Complaint
    • Patient’s condition as described during dispatch.
    • If non-emergency, precisely explain reason for transport.
  • Unit(s)
    • BLS, MICU, ALS Squad
    • Unit numbers
    • Assisting units (often for Paramedic Intercepts)

Arrival & Assessment

  • Scene Assessment
    • Explain what you find.
    • What’s the situation at hand?
  • Initial Observations
    • Your general impression of the patient, skin, eyes, breathing, is patient alert, oriented, etc.?
    • For non-emergencies, does the patient meet medical necessity for use of an ambulance?
  • Reported Complaint
    • What the patient (or family member, witness) tells you
  • Assessment
    • A head-to-toe assessment
    • Use mnemonics (consider explicitly explaining OPQRST reveals, AVPU reveals, etc.)

Treatment & Results

  • Treatment/Interventions
    • A thorough description of what you did
  • Results of Treatment/Interventions
    • The outcome of your treatment decisions
    • How patient responded to what you did
  • Packaging
    • Bandaged, boarded, C-spine stabilization, straps, no straps, etc.
  • How Patient Got to the Ambulance
    • Walked under own power, assisted, wheelchair, stretcher, etc.


  • Transport & Ongoing Condition
    • Patient’s condition enroute
    • Ongoing assessment, additional interventions
    • Patient’s response
    • Where you are taking patient and why
  • Transfer of Care
    • How patient was transferred, sheet lift, log roll, hospital workers assisted, bed number
  • Final Disposition
    • Patient’s condition as transfer is completed.
  • Refusals
    • Document these to the same extent as you would a transport, be thorough, explain what you said and did.
    • Protocols/Medical Command

EMS Documentation Workshop

We encourage everyone to take pride in their documentation.  It reflects on the provider, the agency, and their respective standards of professionalism.

Cornerstone Adminisystems offers EMS documentation workshops to all our client partners, with in-person and virtual options available. For information on hosting a class visit EMS documentation or contact us on becoming a Cornerstone partner.

Compliance Plan


Ambulance organizations need to have a compliance plan, just like billing companies, just like any entity handling sensitive healthcare and financial information. There is no blueprint for how that plan should be designed, and in part because of this, we recommend agencies seek legal counsel in developing their plans.

Certainly, the stories are out there – whistleblowers, strike forces, large settlements, audits, third party contractors paid to find errors, prison time! All legitimate concerns in an age of unparalleled scrutiny on EMS and the medical transport community, leading one to ask: Where does the hammer fall next?

Of course, the best way to approach such concerns is not to worry about hypotheticals, but instead, to focus on what can be controlled. Consider the Evaluation of Corporate Compliance Programs, issued by the U.S. Department of Justice (DOJ) in February 2017.

While specifically intended to address a compliance plan’s effectiveness at determining appropriate resolutions to criminal investigations, the DOJ’s guidance laid out several talking points, most useful for any ambulance organization looking to design a new program or evaluate the effectiveness of an existing one.

Analysis and Remediation of Underlying Misconduct
Focused on root cause analysis, contributing systemic issues, who in the company was involved in making the analysis, and whether there were prior opportunities to detect the issue, such as audit reports.

Senior and Middle Management
Focused on how senior leaders demonstrate leadership in compliance, how senior leadership’s own behavior is monitored, the specific actions taken to demonstrate sound leadership, and how information is shared with others in the company.

Autonomy and Resources
Focused on how compliance functions fit within the corporate hierarchy, the relative autonomy of those personnel, if they are themselves senior leadership or report to senior leadership, how compliance personnel are involved in assessing misconduct or violations, and if the personnel has sufficient experience and credentials.

Policies and Procedures
Focused on process of designing and implementing policies, how they are communicated and enforced, what training the personnel responsible for the policies have received, and how policy effectiveness is evaluated.

Risk Assessment
Focused on how a company identifies, analyzes and addresses its risks, including what metrics and information was used to inform the risk assessment.

Training and Communications
Focused on the extent to which compliance training is tailored to risk areas, how the company assesses the effectiveness of this training, how senior management communicates the company’s position on misconduct, what resources have been made available to staff to provide guidance, and how the company has assessed whether its employees know when to seek advice.

Confidential Reporting and Investigation
Focused on how information is collected, analyzed and used, along with how proper scope is defined, and objectivity ensured, during investigations.

Incentives and Disciplinary Measures
Focused on how employees are held responsible, who is involved in making those determinations, if discipline is administered consistently, and the extent to which incentives exist which promote ethical behavior.

Continuous Improvement, Periodic Testing and Review
Focused on the type, frequency and effectiveness of internal audits, whether they are targeted to his risk areas, how controls are established and measured, and the extent to which updates are made to relevant policies and procedures.