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ACR (comments) writing

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I'm still not confident in my comments section of my ACR writing.I was looking for some examples of generic Comment structures......or if anyone would like to tell me how they learned how to write the comments section.

Does any one know of an ACR writing link?My ACR's are 95% check boxes.I'm just trying to get a nice narrative down in my comments.This is how I would write a sample ACR(below).With each Patient I would change some of the info.I'm looking for a better skeleton structure.Give me all your tips and thought process on how you approach you comments section.

Example

60 y/o male found in hospital bed with rails up awaiting txp to xyz nursing home

Pt states no chief complaints Pt is stable at this time PE revels + ABC -SOB

- JVD +PEARL =L/S =B/L - ABD pain SND NTxQUADS + PMSx4 EXT

- BLEEDING - ECCHYMOSIS - EDEMA TXP pt in POC WOI to nursing home

Sorry I could now make the actual circles around the + and - for you.

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Check your PM's

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When I was going thru Paramedic school I was assigned to MD's in the ED and learned my assessments, treatment and charting from them. We had a patient who crushed his thumb between the trailer hitch and the ball on his truck. I wrote this long speil on the chart describing in detail the above scenario. The Doc took one look at it, ripped it in half and said too wordy. He then grab a new chart and wrote the following...

Crush injury left thumb.

Charting is short and sweet, get to the basics and only the basics. On your example is it necessary in your system to mention the pt was in bed and the rails were up? Also do your charts have separate areas for such things as your PE, if so why repeat it? Also in your example you never stated why the patient was seen in the hospital and what the outcome was.

What you want to do is paint a short picture of who, how, what, & when. How would I write this up, like this.

() indicate where I would use shorthand.

C1 transfer St Bobs Ed to XYZ NH. 60 y/o M, S/P fall @ NH w/ C/C ® hip pain, (-) fx per ed. Pt A&OX3 in no acute distress, PE as noted above. V.S.

B.P. 140/65, HR 65, EKG SR (without) ectopy, RR 16 U/L, SaO2 99% on room air. Non emergent transport with incident.

VS signs can be placed in appropriate boxes if available also. This is just my example, your system may be different.

Peace,

Marty

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Yes this is what Im talking about...more pleas.

....yes I have to say how I found the Pt.They start us off in transport first.They want to see if you can handel (fragile eggs).I transport the oldest sickest people out of E Rs to either nursing homes or hospice care.They die very easily if not properly transported.

They want anal reporting on the comments part.They told me....if you didn't write it you didn't do it.

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All of my run reports have a standard to them. When I did transports, I had to use the charts from the hospitals to determine medical history and such. In doing so, I learned the physicians dictation format. It helps me remember what to document. On traumas, I add another line. But here is my generic format that I use. Keep in mind, I'm doing this as ALS, so you can delete or add whatever is pertinent to your job.

CC : CP

HPI (Stands for history of present illness): Arrived to find male pt sitting on sofa. Pt reports sudden onset of SSCP while at rest at approximately 1700 this date. Pt describes mid-sternal CP radiating to (L) arm. Pt rates pain 7/10. Pt is constant. Pt describes pain as 'an elephant sitting on my chest'. Neg aggravating or alleviating factors. Pt denies any previous episodes of CP. Neg SOB. Neg N/V. Neg dizziness. Neg lightheadedness. Neg syncope. Neg H/A. Neg blurred vision. Neg facial droop. Neg slurred speech. Neg arm drift. Neg recent fever or illness. Neg recent air travel.

PE: (Stands for physical exam)

LOC : CAO x 4.

Skin : N/W/Moderately diaphoretic.

HEENT : (Stands for head, eyes, ears, nose, throat) Pearl. (Includes pain/trauma if needed)

Neck : Neg JVD. Trachea midline. (Includes c/o pain, trauma, if needed)

Chest : Equal expansion. (Includes injuries if a trauma, or lack thereof.)

Lungs : CTA c/ adequate air exchange. SaO2 98% on room air.

Rhythm : NSR s/ ectopy. 12 lead shows definitive ST segment elevation in leads V1, V2, V3, and V4.

Abd : Soft ; non-tender.

Pelvis (I include for trauma only) : Intact. Neg crepitus.

Ext : Neg edema. Full equal pulses. Neg deficits.

Back : (For trauma or pain complaints) Neg deformity noted. Neg c/o pain.

Tx : O2 via nasal @ 6 lpm. 12 lead ECG. NTG 1/150 SL c/ slight relief of CP to 6/10. ASA 324 mg PO. IV NSS lock (L) ACF 18g. Labs drawn x 3. Blood sugar 112 mg/dL. NTG SL 1/150 SL c/ slight relief of CP to 5/10. NTG 1/150 SL c/ slight relief to 4/10. MSO4 4 mg IVP c/ decreased CP to 2/10. NTG Paste 1' transdermally to (L) anterior chest wall. MSO4 2 mg IVP c/ complete releif of CP. Transferred pt care to ED RN in bed 3.

Granted, this is probably more in depth than you need, but the standard is always the same for me. I have been in depositions several times, and the way I document usually precludes me from court. If you didn't write it, it didn't happen. Not to bore you but here is a perfect example why I document the way I do.

Dispatched for a fall. Little old lady tripped over one of those concrete car stopper things in a parking because she didn't see it. Unfortunately, she really did get hurt bad. Fractured her hip, ankle, wrist, and I think something else. In my report I wrote EXACTLY what she said. "I tripped over that parking bump thingy." Long story short, the major food chain store paid for ALL of her medical expenses. She then attempted to sue for millions because she said she tripped in a pothole. After reading my chart, without me going to court, they threw out her lawsuit. I think that food chain owes me a gift certificate, but hey.....

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Scatrat, your report format is very very similar to mine. I also agree that a set format that you use every single run from minor injuries to major injuries to codes is a very very good idea. If you are consistent in documenting you will become very proficient in it and it will likely keep you out of court.

There is a book out there called I believe the "Fourth Protocol" that tells how to write a legally defensible report. This book assumes that you already have a format of a report you use consistently, it goes further and it will have you examining how you write the report. Is it legally defensible in court??? Great book.

Oooops the books name is "The Missing Protocol" it also comes highly recommended by Kate Dernocour.

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Scatrat, your report format is very very similar to mine. I also agree that a set format that you use every single run from minor injuries to major injuries to codes is a very very good idea. If you are consistent in documenting you will become very proficient in it and it will likely keep you out of court.

There is a book out there called I believe the "Fourth Protocol" that tells how to write a legally defensible report. This book assumes that you already have a format of a report you use consistently, it goes further and it will have you examining how you write the report. Is it legally defensible in court??? Great book.

Oooops the books name is "The Missing Protocol" it also comes highly recommended by Kate Dernocour.

Any idea where to find it? I mean other than Amazon? They don't always have those weird little medical books. I might be interested in reading it.

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60 y/o male found in hospital bed with rails up awaiting txp to xyz nursing home

Pt states no chief complaints Pt is stable at this time PE revels + ABC -SOB

- JVD +PEARL =L/S =B/L - ABD pain SND NTxQUADS + PMSx4 EXT

- BLEEDING - ECCHYMOSIS - EDEMA TXP pt in POC WOI to nursing home

Sorry I could now make the actual circles around the + and - for you.

"Pt t/p from ABC Hospital ---> XYZ nh for rehab p tx of fx R hip c repair. T/p via stretcher s incidents or [change], care left c medical staff. "

Which is actually about twice as much as my company wants.

Emergency runs, they get something between what you wrote and what scratrat wrote.

NTG Paste 1'

Ummmm..... :P:lol::lol:

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I LOVE YOU GUYS!!!!!! This is why I love this board.Now I understand what the saying means ............

(Welcome to the brother/sister hood of EMS.)

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I have the same question, i'm never sure if my narratives are good enough! Heres an example of a narrative (i'm bls).

Upon arrrival, found pt sitting upright in chair in her home, a & o x4, pt states she had a mechanical fall due to dizziness and suffered an approx 1 in partial thickness lac on anterior right scalp. My partner flushed the wound with sterile saline and bandaged with gauze while I assessed vitals which were in normal limits and obtained SAMPLE. Pt ambulated approx 2 feet to gurney where we assisted in getting her seated and strapped on. Loaded pt into ambulance. En route, reassessed vitals once which were still normal and pt rested in POC with no interventions. Arrived at xyz hosp w/o incident.

Now, i dont list exact vitals because those are in my PCR anyways, as well as medical history, allergies etc.. Its gotten much better too, lol, i used to be horrible in the narratives, forgetting about things like interventions (if any, or noting none), and how pt got on gurney (alone or assisted) etc.

Caryn

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"My partner did this while I did that." "Assisted in getting her seated." Who cares? WAY more info in there than there needs to be.

"Pt found seated in chair AO x 4/4. Pt c/o mechanical fall from standing --> floor [secondary to symbol] dizziness. 1" lac R anterior scalp. Wound flushed/dressed. Vitals as noted. Pt-->stretcher-->truck-->ED [without] incidents or [change]."

Done. Six lines condensed down to two and a half, and much more professional-sounding to boot.

Granted I typically document more than that for such a call (a few more assessments, plus pertinent negatives and such), but if I was going to write what you did, that's how its done.

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Thanks!

The only reason I state how the pt got to the gurney is because my FTO would ask me "and what, she walked to the ambulance and got in and seated herself??" and tho *I* didnt think its really pertinent unless the pt is immobile, i now put that down whether she walked to the gurney, we manually maneuvered her, or what. Good idea on the vitals, ill do that next time for sure, as well as shortening the treatment stuff on the lac!

Caryn

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Remember the purpose(s) of charting. First it is a legal documentation (charting) of what you found, assessed, treated/intervention, and evaluation, and plan. Second, where most do not understand, it is for billing purposes as well. This is the reason for documenting if they were non-ambulatory, bed ridden, etc.. If it is not documented and paint a picture that stretcher or treatment/monitoring required, chances are your EMS is not going to be reimbursed for their services. Thus, what does not come in does not go out.. = no pay, no raises, etc.

My suggestion is to look at your company protocol and manual. Each should have an approved medical abbreviation(s) and format. This is what the attorneys and legal system will examine. Each hospital has an approved medical terminology and abbreviation list, this prevents people making up their own. If you don't have one, I suggest to discuss with the administrator to develop one.

Look at charting and documentation of others. Charting and documentation is an art, and skill like any other skill in EMS. I personally document my physical examination similar to a physician, including pertinent negatives to prove that I did assess and evaluate or rule out, as well as in-depth follow up. I also include time & whom, I made any type of verbal report per cell phone , etc.

R/r 911

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The only reason I state how the pt got to the gurney is because my FTO would ask me "and what, she walked to the ambulance and got in and seated herself??" and tho *I* didnt think its really pertinent unless the pt is immobile, i now put that down whether she walked to the gurney, we manually maneuvered her, or what.

I'm surprised they really want you to be that specific, because walking to the stretcher (or walking to the ambulance) means you aren't getting paid by Medicare for that run. But hey, if they REALLY want you to, by all means. If they're like a local company here that hands back unpaid run forms to be re-written, tell them to kiss your ass.

My favorite is when the college we go to walks two drunks to the truck and wants us to take both. Company "policy" is that nobody walks, ergo you have no reason to document that somebody walked to the truck- everybody gets the stretcher. Ok, so how am I supposed to document that I transported two different people to on the stretcher at the same time? Granted these kids don't have Medicare, but still.

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In my opinion this has to be one of the "best" written threads I have ever see on EMT CITY.I can use just about everything from every one of these posts.

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I have a format I follow for interfacility transfers:

1) State where we arrived and who we found: "XYZ unit AOS @ sending facility to find X y/o male/female pt supine in bed"

2) State how pt presents: "Pt presented AOx4, C/O L hip pain, 6/10. Pt obese (130kg) , agitated, diaphoretic"

3) State why the pt was admitted + what important drugs they are on: "Pt admitted D/T L hip pain / secondary to hip FX from mechanical fall. Pt given 5mg Morphine by sending facility."

4) State how we moved the pt including info showing why an ambulance is req for transfer: "Multiple attendants req to carefully slide pt to/from gurney"

5) State what we provided pt and what happened during transfer with more reason for transfer: "En route monitored vitals (166/90, 86 , 16) provided orthopedic wedge between legs.Pt is HTN C/O of L hip pain 8/10 with Hx of CHF."

6) State where we took them and why: "Transferred to recieving facility for XRAY of L hip/leg, service not provided at sending facility."

End Result:

XYZ unit AOS @ sending facility to find 75 y/o male pt supine in bed. Pt presented AOx4, C/O L hip pain, 6/10. Pt obese (130kg) , agitated, diaphoretic. Pt admitted D/T L hip pain / secondary to hip FX from mechanical fall. PT given 5mg Morphine by sending facility. Multiple attendants req to carefully slide pt to/from gurney. En route monitored vitals (166/90, 86 , 16) provided orthopedic wedge between legs. Pt is HTN C/O of L hip pain 8/10. Hx of CHF,ETOH,Arthritus. Transferred to recieving facility for XRAY of L hip/leg, service not provided at sending facility.

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I'm surprised they really want you to be that specific, because walking to the stretcher (or walking to the ambulance) means you aren't getting paid by Medicare for that run. But hey, if they REALLY want you to, by all means. If they're like a local company here that hands back unpaid run forms to be re-written, tell them to kiss your ass.

My favorite is when the college we go to walks two drunks to the truck and wants us to take both. Company "policy" is that nobody walks, ergo you have no reason to document that somebody walked to the truck- everybody gets the stretcher. Ok, so how am I supposed to document that I transported two different people to on the stretcher at the same time? Granted these kids don't have Medicare, but still.

I am somewhat but not totally shocked that you would not document exactly what happened. If your pt. walked to the stretcher or to the ambulance, than that is what you document. If your employer doesn't get paid for the run, than so be it. But to actually and obviously omit something is just plain fraud.
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I am somewhat but not totally shocked that you would not document exactly what happened. If your pt. walked to the stretcher or to the ambulance, than that is what you document. If your employer doesn't get paid for the run, than so be it. But to actually and obviously omit something is just plain fraud.

I prefer to write my run forms once. If I document no-pay criteria, I'm going to be told to re-write it.

It's the re-write that would be fraud.

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I prefer to write my run forms once. If I document no-pay criteria, I'm going to be told to re-write it.

It's the re-write that would be fraud.

If you document the first time what exactly happened, you shouldn't have to re-write it. If you change it to include something else, than you are correct, that would be the fraud. However, including something in your original ACR that did or didn't happen is also fraud.
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If you document the first time what exactly happened, you shouldn't have to re-write it. If you change it to include something else, than you are correct, that would be the fraud. However, including something in your original ACR that did or didn't happen is also fraud.

You're right, I shouldn't have to. However, documenting that someone walked to the truck, for example, would be to admit a violation of company policy- "nobody walks." Of course, management could really care less whether the patient walks or not, they know the kinds of idiots we deal with. They just don't want us documenting it, because that costs them money. So they invent a punishable offense around it for use if somebody really insists on being a problem for them.

If I don't play the game, I run the risk of being fired- and having to find employment at another private company with the same rules. Me personally, I'd rather keep my seniority than bounce from company to company until there aren't any left that I don't have a reputation at.

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You're right, I shouldn't have to. However, documenting that someone walked to the truck, for example, would be to admit a violation of company policy- "nobody walks." Of course, management could really care less whether the patient walks or not, they know the kinds of idiots we deal with. They just don't want us documenting it, because that costs them money. So they invent a punishable offense around it for use if somebody really insists on being a problem for them.

If I don't play the game, I run the risk of being fired- and having to find employment at another private company with the same rules. Me personally, I'd rather keep my seniority than bounce from company to company until there aren't any left that I don't have a reputation at.

Although this may make your life more difficult, I'd say screw your employer and write what happened. If you go to court, guess who takes the blame? If you think for one minute that your employer will take the stand and say "we tell them to omit the fact that this person walked", then you are sadly mistaken.

And if they threathen to fire you, call medicare and report them for fruad. If medicare investigates and fines the company, you can get a portion of the proceeds. Granted, this probably makes life worse, but that company can't fire you for it, or risk being sued for wrongful termination, and they can't inform any further employers. It's against the law.

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And if they threathen to fire you, call medicare and report them for fruad. If medicare investigates and fines the company, you can get a portion of the proceeds. Granted, this probably makes life worse, but that company can't fire you for it, or risk being sued for wrongful termination, and they can't inform any further employers. It's against the law.

And then there is the real world.

You WILL get fired. It will be for being five minutes late for work (even though you weren't), or for not pressing your shirt well enough, or for an anonymous complaint from a nursing home employee, or for not cleaning your truck well enough, or for leaving two sheets but only one pillow case for the next crew, or for forgetting to dot an I on a run report. There won't be a thing in writing about it being related to your fraud complaint, but we all know that it really is. And the government won't even attempt to do a thing about it. And you can't afford the attorney to fight it. And would you really fight it even if you could afford the attorney?

Sorry, kids. This is a lose-lose situation. If you honestly believe otherwise, then you don't want to hear what I have to say about Santa Claus.

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And then there is the real world.

EXACTLY.

You WILL get fired. It will be for being five minutes late for work (even though you weren't), or for not pressing your shirt well enough, or for an anonymous complaint from a nursing home employee, or for not cleaning your truck well enough, or for leaving two sheets but only one pillow case for the next crew, or for forgetting to dot an I on a run report. There won't be a thing in writing about it being related to your fraud complaint, but we all know that it really is. And the government won't even attempt to do a thing about it. And you can't afford the attorney to fight it. And would you really fight it even if you could afford the attorney?

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