To prepare quality patient care reports for smooth patient transfer, emergency medical staff need to adhere to some important considerations.

1. Ensure Proper Clinical Handover with
Quality Patient Care Reports
To prepare quality patient care reports for
smooth patient transfer, emergency
medical staff need to adhere to some
important considerations.
MTS Transcription Services
United States

2. Proper communication among clinicians is crucial to prevent adverse events in healthcare
and medical transcription companies play a key role in ensuring this with accurate and
timely documentation. This is all the more critical when it comes to emergency medical
services (EMS). Paramedics or EMS staff need to prepare detailed emergency care reports
(ECRs) to provide downstream healthcare providers with a clear idea about the patient’s
needs. This is necessary to improve the quality and continuity of care. The Journal of
Emergency Medical Services (JEMS) Magazine recently published a 5-part series on how
emergency staff can prepare goodpatient care reports (PCRs). This article summarizes the
key points.
The Five Criteria for Well Written PCRs
EMS staff need to go by five criteria to produce comprehensive PCRs:
• Collect all necessary information
• Avoid vague terminology
• Justify the medical interventions reported
• Provide a detailed narrative
• Ensure legibility of signatures and hand-written information
✓ Collect all necessary information: PCRs should contain the following details:
- Detailed dispatch information to validate the reason and level of response
- Patient demographic information
- Patient insurance coverage details
- Chief medical complaint upon arrival and when symptoms started
- Detailed primary and secondary assessment information based on symptoms
communicated during the assessment and clinical findings
- Full information about medical procedures performed and the results
- The EMS staff’s impression about the patient’s condition
• Avoid vague terminology: To provide a clear clinical picture of the signs and
symptoms of the patient at the time of transport, avoid using vague terminology in
the PCR. The aim should be as specific and descriptive as possible. Values of
assessments of blood pressure and glucose levels should be provided.
• Justify the medical interventions reported: This is important for the continued
care of the patient as well as to reduce denial of claims. It is necessary to report the
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3. medical procedures performed clearly, explain why they were performed, and
provide details aboutthe assessment, any changes in the patient’s condition, and the
outcome.
• Provide a detailed narrative: The narrative for the PCR shouldinclude a detailed
explanation of medical necessity and why transport by EMS was required. Medical
monitoring of the patient and secondary exam performed during transportation to
the hospital should also be provided. EMS staff should report the patient’s symptoms
and interventions to manage the symptoms.
• Legibility of signatures and hand-written information: Patient and provider
signatures in the PCR should be legible. If signatures are not legible, the name
should be printed or typed in the report. If the patient is unable to sign the report, a
family member should do so. The report should also have crew members’ physical
and/or electronic signatures and credentials. The person who receives the patient at
the healthcare facility should also sign the PCR. Any handwritten notes and forms
attached to the PCR should also be clear and legible.
The main concern of paramedics is to provide proper patient care in emergency situations.
Outsourcing medical transcription helps them focus on their primary tasks and ensure
quality PCRs. Partnering with an experienced medical transcription company that has skilled
medical transcriptionists on board will allow EMS providers to craft robust, accurate
electronic PCRs, avoid omissions or delays in documentation, and ensure proper patient
transfer.
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