What is the optimal template for a pre-hospital (Emergency Medical Services, EMS) narrative to ensure billing compliance, accurate documentation, legal protection, and educational value?

From the Guidelines

A comprehensive pre-hospital narrative template should follow a chronological SOAP format (Subjective, Objective, Assessment, Plan) with specific documentation elements, as this structure supports medical necessity for interventions, establishes the standard of care, creates a legal record, and provides valuable information for quality improvement and education purposes.

Key Elements of the Template

The template should begin with dispatch information including time, nature of call, and response priority.

• Document the scene assessment noting safety concerns, mechanism of injury for trauma, or environmental factors for medical calls.
• For subjective information, record the chief complaint in the patient's own words, history of present illness with onset, duration and progression, pertinent past medical history, medications, allergies, and last oral intake.
• The objective section should include vital signs with times, physical examination findings organized by body system, relevant negative findings, and any changes in patient condition.
• Document all interventions chronologically with specific medication names, doses, routes, times, and patient responses.
• Include reassessment findings after each intervention.
• The assessment section should state your field impression or working diagnosis with supporting evidence.
• Finally, document your treatment plan, patient disposition, any changes during transport, and hand-off information including to whom you transferred care, as emphasized by the American Heart Association in their policy statement on emergency medical services within stroke systems of care 1.

Importance of Accurate Documentation

Accurate and comprehensive documentation is crucial for legal protection, billing compliance, and educational value, as highlighted in the policy position paper from the American College of Physicians on clinical documentation in the 21st century 1.

• It ensures that the medical record is accurate and reliable, which is essential for patient care and legal purposes.
• It also facilitates communication among healthcare providers, promotes continuity of care, and supports quality improvement initiatives.
• Furthermore, accurate documentation is necessary for billing and reimbursement purposes, as incorrect coding can lead to billing fraud and penalties, as noted in the report by the Office of Inspector General of the U.S. Department of Health and Human Services 1.

From the Research

Template for Pre-Hospital Narrative

To create a template for a pre-hospital narrative that maximizes billing compliance, accurate documentation, legal protection, and educational value, the following elements should be considered:

• Fixed System Variables: Include information about the pre-hospital service, such as the unit's identification, location, and time of response 2.
• Event Operational Descriptors: Document the details of the event, including the type of emergency, the number of patients, and the level of care provided 2.
• Patient Descriptors: Record patient information, such as demographics, medical history, and chief complaints 2.
• Process Mapping: Outline the sequence of events, including the assessment, treatment, and transportation of the patient 2.
• Outcome Measures and Quality Indicators: Track patient outcomes, such as vital signs, treatment effectiveness, and any complications that may have arisen 2.

Key Components

The template should also include:

• Standardized Reporting: Use a standardized format for reporting time variables, chief complaints, and diagnostic and therapeutic procedures to ensure consistency and accuracy 2.
• Clear and Concise Language: Use simple and concise language to facilitate understanding and minimize errors 2.
• Relevant Clinical Information: Include all relevant clinical information, such as patient symptoms, medical history, and treatment provided, to ensure comprehensive documentation 2.

Educational Value

The template can also serve as a tool for education and training, by:

• Providing a Framework: Offering a structured framework for documenting pre-hospital care, which can help guide healthcare providers in their assessment and treatment of patients 2.
• Promoting Critical Thinking: Encouraging healthcare providers to think critically about patient care and document their thought process and decision-making 2.