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Patient Care Report (PCR) Documentation Training It is all in the DETAILS!

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Page 1: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Patient Care Report (PCR)

Documentation Training

It is all in the DETAILS!

Page 2: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Introduction

Completion Time: 00:46

• Course Overview

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Page 3: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Module 1: Introduction & Overview

Completion Time: 21:38

• Importance of Documentation

• Painting the Entire Picture

• Back to Basic

• SOAP

• CHART

• OPQRST

• AVPU

• DOTS

• SAMPLE

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Page 4: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Module 2: The Journey to ICD-10 &

Documentation Challenges

Completion Time: 7:04

• EMS|MC’s Commitment

• Challenges

• ICD-10 Overview

• ICD-9 vs ICD-10

• Effect on Documentation

• Specificity

• Laterality

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Page 5: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Module 3: The Anatomy of

Documentation

Completion Time: 25:15

• Patient Demographics

• Date & Time of Dispatch

• Symptoms at Dispatch

• Symptoms at Arrival

• Emergency vs Non-emergency

• Assessment & Interventions

• Medications, Supplies & Equip.

• Origins & Destinations

• Loaded Patient Mileage

• Parts of a PCR

• Dropdown boxes

• Narrative

• Types of Insurance

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Page 6: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Module 4: Medical Necessity & Painting a

Picture for Emergency Dispatches

Completion Time: 15:15

• Certificate of Medical

Necessity

• Medicare & Medical Necessity

• Billing Condition Codes

• Painting a Picture

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Page 7: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Module 5: Non-Emergency Transfers

& Covered Destinations

Completion Time: 16:47

• Non-Emergency Transfers

• Bed-Confined

• Stretcher-Bound

• PCS & PCR

• Match

• Contradictions

• Prior Authorizations

• Nearest Appropriate Facility

• Locality Rule

• Covered Destinations

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Page 8: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Module 6: Special Transport

Situations

Completion Time: 10:43

• Deceased Patients

• Prior to 911

• Prior to Transport

• En route to Hospital

• Multiple Patients

• Medicaid Maternity Patients

• Hospice Patients

• Mutual Aid

• Paramedic Intercept

• Transfer of Care

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Page 9: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Module 7: Levels of Service

Completion Time: 6:49

• BLS

• ALS

• ALS-2

• SCT

• Interventions

• Initiated

• Monitored

• Attempted

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Page 10: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Module 8: Claim Submission

Signatures

Completion Time: 8:42

• Required Signatures

• Medical Author

• Billing Signature

• Billing Signature Options

• Patient Signature or Mark

• Authorized Representative

• Ambulance Crew & Receiving

Facility

• Valid Unable to Sign Reasons

• Refusal to Sign

• Effects of Missing Signatures

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Page 11: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Module 9: Documentation

Training Review

Completion Time: 17:11

• Recap of Course

• ICD-9 vs ICD-10 Narrative Comparisons

• Non-Emergency Transport

• Trauma Transport x2

• Chest Pain Transport x2

• Dehydration Transport

• Mobility Transport x2

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Page 12: Patient Care Report (PCR) Documentation Training · Module 3: The Anatomy of Documentation Completion Time: 25:15 • Patient Demographics • Date & Time of Dispatch • Symptoms

Certificate of Completion

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