2. Overview of Lesson Topics
• Functions of the prehospital care report (PCR)
• Collection of data in PCRs
• Legal concerns
• Special situations
• Documentation methods
• Medical abbreviations
3. Introduction
• Documentation of information about EMS calls serves several
purposes.
• The record of care provided is called a patient care report
(PCR).
• Thorough, accurate documentation is a critical EMT skill.
4. Functions of the PCR
• Continuity of medical care
• Administrative uses
• Legal uses
• Information for education and research
• Evaluation and continuous quality improvement (CQI)
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5. Functions of the PCR
• Continuity of medical care
• Emergency department (ED) personnel need a record of the
patient's prehospital condition and treatment in order to
provide the best patient care.
• Prehospital information about the patient provides a baseline
for further evaluation of the patient's condition.
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6. Functions of the PCR
• Administrative uses
• Billing and insurance reimbursement
• Statistical information for future planning
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7. Functions of the PCR
• Legal uses
• The patient may be a crime victim or perpetrator
whose injuries must be documented.
• Protection in the event of a civil lawsuit.
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8. Functions of the PCR
• Education and research
• PCRs can be a rich source of data to allow research
on many issues.
• PCRs can provide information needed for continuing
education planning.
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9. Functions of the PCR
• CQI
• CQI is an essential process in all EMS systems.
• PCRs provide data for comparison against protocols
and standards of care.
10. Collection of Data in PCRs
• All documentation must be careful and thorough.
• There are paper and electronic PCRs.
15. Collection of Data in PCRs
• Two basic rules of PCRs
• If it wasn't written down, it wasn't done.
• If it wasn't done, don't write it down.
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16. Collection of Data in PCRs
•Minimum data set
• Two parts
• Patient information
• Administrative information
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17. Collection of Data in PCRs
• Patient information
▪ Patient demographics
▪ Chief complaint
▪ Level of responsiveness
▪ Blood pressure
▪ Skin perfusion, color,
temperature
▪ Pulse rate
▪ Respiratory rate and
effort
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18. Collection of Data in PCRs
• Administrative information
• Time incident was reported
• Time EMS unit was notified
• Time of arrival at patient
• Time unit left the scene
• Time unit arrived at destination
• Time care was transferred
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19. Collection of Data in PCRs
• PCRs usually have these sections:
• Administrative information
• Patient demographic
• Vital signs
• Patient narrative
• Treatment
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20. Collection of Data in PCRs
• Administrative information
• EMS unit number or call number
• Names and levels of certification of crew members
• Address of call location
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21. Collection of Data in PCRs
• Patient demographic and other data
• Patient's name, age, sex
• Patient's home address
• Insurance and billing information
• Location patient was found
• Care given before EMTs' arrival
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22. Collection of Data in PCRs
• Vital signs
• At least two sets of vital signs are needed.
• Record the patient's position when vitals were obtained.
• Document the time vitals were obtained.
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23. Collection of Data in PCRs
• Patient narrative
• Provide a brief, but thorough picture of the patient and his
problem for other medical personnel to use.
• Includes the chief complaint, patient's history, and physical
exam findings.
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24. Collection of Data in PCRs
• Patient narrative
• Objective information is verifiable or measurable.
• Subjective information is based on perceptions or opinions.
• Pertinent negatives are signs and symptoms that might be
expected, but which are not found.
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25. Collection of Data in PCRs
• Patient narrative
• Information from the physical exam and pertinent scene
information.
• Document the source of information.
• Use a simple, direct style; no codes or nonstandard
abbreviations.
• Select proper medical terms and spell them correctly.
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26. Collection of Data in PCRs
• Treatment
• Detail treatment in chronological order.
• Document the time of each treatment.
• Document the patient's response to each treatment.
27. Legal Concerns
• Legal concerns include:
• Confidentiality
• Distribution
• Refusal of treatment
• Falsification
• Correcting errors
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28. Confidentiality
• The PCR contains information that is confidential and
which cannot shared with unauthorized individuals.
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29. Distribution
• Specific instances in which PCR information can be
distributed include:
• To health care providers continuing patient care
• Police, when needed for a criminal investigation
• Third parties for billing purposes
• Upon subpoena
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30. Distribution
• Copies of PCR may be distributed according to state
laws and protocols, including:
• Leaving a copy with the receiving facility
• A copy retained by the EMS service
• Copies for medical oversight and CQI
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31. Refusal of treatment
• Legal issues arise when a patient refuses care.
• Obtain as much information as possible to try to
persuade the patient to accept care.
• Inform patient of consequences of refusing care.
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32. Refusal of treatment
• Determine patient's competence to refuse care.
• Document the following information:
• Your assessment findings
• Any emergency care you provided
• Your explanation of the consequences of refusing care
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33. Refusal of treatment
• Document the following information:
• If the patient refused any or all components of assessment
and the treatment offered.
• The patient's mental status, to establish that he/she was
competent to make the decision to refuse care.
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34. Refusal of treatment
• Have the patient, and if possible, a witness sign the
refusal form.
• If the patient refuses to sign, obtain a signature from a
witness who can verify the refusal.
• Complete all sections of the refusal form.
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36. Refusal of treatment
• When a patient refuses care, advise him of alternative
ways to obtain transportation and care.
• Explain signs and symptoms that could indicate his
condition is worsening.
• Explain that if the patient changes his mind, he can call
at any time.
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37. Falsification
• PCRs must be thorough and accurate.
• Mistakes or omissions in care must be documented
accurately.
• Never provide false information in a PCR.
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38. Falsification
• Falsification of PCR information can lead to loss of
licensure and, possibly, criminal charges.
• Falsification compromises patient care.
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39. Correction of errors
• To correct errors in documentation
• Draw a single line through the mistake.
• Provide the correct information.
• Write the date and time of the correction.
40. The proper way of correcting an error in a prehospital
care report is to draw a single line through the error,
initial it, and write the correct information beside it.
41. Special Situations
• Transfer of care
• When it is not possible to complete the PCR and
obtain a signature from the person accepting patient
care before leaving the facility, a special transfer-of-
care form may be used.
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42. Special Situations
• Multiple-casualty incidents
• Demands of the situation may not allow completion
of PCRs.
• Triage tags can be used to communicate basic
patient information.
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43. Special Situations
• Special reports may be required for:
• Suspected child or elder abuse
• Possible infectious disease exposure
• Injury to the EMS provider
• Situations requiring additional documentation or notification of
other agencies
44. Alternative Documentation Methods
• Several formats for narrative documentation are
represented by mnemonics.
• SOAP
• CHART
• CHEATED
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46. Alternative Documentation Methods
• SOAP
• Subjective information is what the patient tells you.
• Includes symptoms
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47. Alternative Documentation Methods
• SOAP
• Objective information consists of signs you can detect with
your senses.
• Includes the observations made in the physical exam
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48. Alternative Documentation Methods
• SOAP
• Assessment is your impression of the patient based on
evaluation of the subjective and objective information.
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52. Alternative Documentation Methods
• CHART
• Chief complaint is what the patient says is the reason for
seeking medical care.
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53. Alternative Documentation Methods
• CHART
• History includes the SAMPLE history
• Symptoms
• Allergies
• Medications
• Past medical history
• Last oral intake
• Events leading to the problem
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54. Alternative Documentation Methods
• CHART
• Assessment includes findings from the primary and secondary
assessments, detailed physical exam, and ongoing
assessment.
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56. Alternative Documentation Methods
• CHART
• Transport describes how the patient was transported
and any changes in his condition during transport.
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59. Lesson Summary
• PCRs serve several purposes.
• Continuity of medical care
• Administrative uses
• Legal uses
• Education and research
• Evaluation and CQI
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60. Lesson Summary
• Characteristics of good documentation
• Thorough and accurate
• Contains acceptable objective and subjective information
• Is legible
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61. Lesson Summary
• Thoroughly document refusals of care.
• Never falsify PCR information.
• Correct PCR errors properly.
