The document discusses the importance and functions of prehospital patient care reports (PPCRs). PPCRs serve several important purposes: as a medical record, for continuity of care, administrative/billing purposes, legal protection, education, and quality improvement. The document outlines the components and proper format of PPCRs, including the use of standardized templates, chronological documentation of assessments and treatments, and guidelines for special situations like mass casualty incidents or patient refusals. Accurate, objective, and complete documentation is emphasized.

1. Documentation

2. Prehospital Pt Care Report (PPCR) What Standardized pt record used in EMS Systematic collection of data from dispatch through tx to hospital Functions Documentation of pt C/C, MOI, NOI, Hx, and treatments, refusals Some items Time – Location – Assessments – Rx – Changes in Condition

3. PPCR Functions Medical Record Continuity of Care Medical report of prehospital care Physician review for treatment MOI, NOI, Chronology of S/S, Vitals, etc Educational Demonstrates proper documentation How to handle unusual situations/events Administrative Billing Service Statistics Research Evaluation/CE Continuous QI Improving different components of EMS through evaluation of call sheets and pt Rx

4. PPCR Functions Legal Document PROTECTION FROM LAWSUITS IF YOU DON’T WRITE IT DOWN YOU DIDN’T DO IT!!!!!!!! Generally the writer is the one who goes to court with the PPCR Accurate times Status of pt upon arrival at scene, during tx Emergency treatment provided Changes in condition en route to hospital Any unusual events that occurred during the call

5. PPCR Components Minimal Data Set Pt Information C/C LOC Vital signs B/P Perfusion status Pulse Rate Resp Rate and Quality Skin Color and Temp Administrative Information (Military Time) Time call was reported Time unit signed en route Time unit arrived on scene Time of arrival at pt Time unit left scene Time of arrival at destination Time of transfer of care

6. PPCR Types/Sections Types Traditional written form Digital/Computer based Run Data Date – Times – Unit # - Service – Crew Names Pt Data Name – Address- DOB – Insurance Info – Sex – Age NOI/MOI – Pt Location – Rx given prior to arrival S/S – Rx administered – Baseline Vitals – SAMPLE Hx Changes in condition -Receiving Facility – Specialty Tx mode Rationale for receiving facility Check Boxes Be sure to fill in box completely Avoid stray marks

7. PPCR Narrative Narrative Describe, don’t conclude Include pertinent negatives Record observations about the scene Avoid radio codes Use standard abbreviations When sensitive information is obtained note the source State reporting requirements Spell correctly For EVERY assessment record time and findings.

8. Narrative Methods C.H.A.R.T. C omplaint H istory A ssessment R x-Treatment T ransport S.O.A.P S ubjective What Pt/bystanders says in their “own words” C/C, SAMPLE/OPQRST O bjective What YOU see/measure in assessment Scene size up, Assessment findings, Vitals, A ssessment What YOU think is wrong Conclusion/Clinical impression P lan Treatments occurred, treatments planned C.H.E.A.T.E.D. C hief Complaint H istory E xamination A ssessment T reatment E valuation Did treatment help D isposition Final outcome

9. PPCR Distribution Confidentiality The form and its contents are confidential Distribution Determined by local and state protocols Written release not needed… Receiving facility,Transporting agencies Continuation of care 3 rd party billing info Continuing education (remove pt ID) Sate law (rape, abuse, GSW) Subpoena 12VAC5-31-950. Disclosure of patient information.

10. PPCR Falsification Issues Error of omission/commission Document what did/did not happen What steps if any were done to correct it Falsification Revocation of certification Improper pt care due to incorrect assessment Areas of difficulty Vital Signs Document on the ones there were TAKEN Treatments Do not chart procedures there were not performed

11. Pt Refusals COMPETENT adult pt have the right to refuse care at any time Before you leave the scene you should: Try to persuade pt to go to hospital Ensure pt is able to make informed decision Inform pt of why he/she should go & what could happen if he/she does not go Consult med control if need be If pt still refuses Document assessment findings Document any Rx Have pt sign refusal Have a family member, by stander, police sign as witness If pt refuses to sign refusal Have a family member, by stander, police sign as witness

12. Pt Refusals Complete PPCR Complete Pt assessment Care EMT-B wished to provide to pt Statement that the EMT-B explained to pt possible consequences of refusal including death Offer alternative methods of obtaining care State willingness to return

13. Correcting Errors in Documentation Errors made while writing PPCR Draw single horizontal line through error and initial it Write correct info beside line Do not attempt to obliterate the error Errors discovered after report has been written Draw single horizontal line through error Initial and date it Attach a note with the correct info If info was omitted attach a note with date and EMT’s initials

14. Special Situations Mass Casualty Incidents MCI Use of Triage Tags Basic Pt ID data Major Injuries Baseline Vitals Triage Status Local plans have guidelines for MCI When there is not enough time to fill out report before next call: Fill the PPCR out later

16. Documentation of Death Documentation of Death Withholding treatment if irreversible brain damage can be proven in pt in cardiac arrest Note ALL factors that denote obvious death including/but not limited to : Decapitation Transection of chest and/or abd Rigor mortis Lividity Decomposition Charring of the body Extensive head trauma Chest injury/trauma indicative of mortal injury Other bodily disfigurement indicative of mortal injury

19. Special Situations Special Situation Reports Used to document events that should be reported to local authorities or to supplement primary report i.e. Exposure/Injury/Lost property Submitted in timely manner to authority per protocol Accurate and objective EMT-B should keep copy for records

20. Effectiveness of PPRC Accuracy & Honesty State C/C in pt own words “I hurt all over” “Feels like an elephant sitting on my chest” Accurate vital signs Describe your findings NOT conclusions “Pt was found disoriented on the apartment floor with an alcohol-like odor on his breath” NOT “Pt was found drunk on the floor of the apartment”

21. Effectiveness of PPRC Continued Clarity Print legibly Black/blue ink Approved shorthand/abbreviations Correct spelling EXACT location of pain/injury “substernal chest pain” “Puncture wound on anterior chest approx 3 cm off midline”

22. Some Common Abbreviations Female Male a= Before p = After BP= Blood pressure BVM = Bag Valve Mask c= With s= without c/o = complains of CPR DOB = Date of Birth, y/o = Year old Hx = History LLQ = Left Lower Quadrant, LUQ = Left Upper Quadrant NTG = Nitroglycerin O 2 = Oxygen po= By Mouth SL= Sublingual Pt= Patient Px= Physical Exam RLQ= Right lower Quadrant, RUQ = Right Upper Quadrant Tx = Treatment NRB = Non Rebreather NC= Nasal Cannula

23. Effectiveness of PPRC Chronology and Trends Time relationship of : Response- Assessment- Treatment – Transport – Arrival Provides physician with Hx of events Provides trends and responses to treatment i.e. SOB pt c O 2 = Relieved hypoxia – Improved O 2 sats

24. Time Resp Pulse B/P LOC Pupils Skin 16 90 120 A PERRL Cool/Moist/Pale Regular Regular 80 18:10 22 110 110 A PERRL Cool/Moist/Pale Shallow Regular 84 18:15 28 140 90 Voice Dilated Cool/Moist/Pale Shallow Regular 70 What trends do you see? What do you think might be causing this???

25. Effectiveness of PPRC Completeness Record all assessment, treatments, reassessments +/- findings “ Pt c/o severe squeezing chest pain on L side but denies radiation” Events that affected treatment/transport Prolonged extrications Role of other providers on scene Treatments provided by lay people CPR, 1 st Aid Other unusual occurrences Belligerent/aggressive pt Removal of items from pt

26. One Last Rule… Document… Document… Document…