The following are examples of administrative information

PATIENT CARE REPORTS PCR Flashcards Why do we document ?Education and researchAdministrative usesQuality improvement Documenting refusal of careEven if the patient refuses care, you must complete the PCR. You will need to document the advice you gave as to the risks associated with refusal of care.Have the patient sign a refusal form. You should also have a family member, police officer, or bystander sign the form as a witness. If the patient refuses to sign the refusal form, have a family member, police officer, or bystander sign the form verifying that the patient refused to sign.The following are examples of administrative information

gathered from a PCR:

• time the incident was reported-time the EMS unit was

notified- time thenEMS unit arrived on scene- time the EMS unit left the scene- time the EMS unit arrived at the receiving facility- time the patient care was transferred The report serves the following six functions : 1. Continuity of care2. Legal documentation3. Education4.Administration information5. Essential research record6.Evaluation and continuous quality improvement The following are examples of information collected on a

PCR :

• chief complaint- level of consciousness ( according to the

AVPU scale) or mental status- vital signs- initial assessment- patient demographics ( age, gender, ethnic background ) Sample uniform components of a PCRPatients name , gender, date of birth, and address.Dispatched as ( when was the ambulance called ?What was the nature of the call as reported by the dispatcher?)Chief complaintLocation of the patient when first seen (including specific details , especially if the incident is a car crash or when criminal activity suspected)Rescue in treatment given before your arrivalsigns and symptoms found during your patient assessmentcare and treatment given by you at the site in during transportresponse to treatmentvital signsSAMPLE historychanges in vital signs and conditionadditional orders received from the hospitalName of person receiving the patient reportdate of the calltime of the calllocation of the calltime of dispatchtime of arrival at the scenetime of leaving the scenetime of arrival at the hospitalpatient insurance informationnames and/ or certification numbers of the EMTs who responded to the callname of the

transport destinationtype of run to the scene: emergency or

routine

Several methods of documentation are used including the

following:

CHART or CHARTE method stands for chief complaint, history and physical examination, assessment, treatment (RX) and transport. To use CHARTE, add exceptions.SOAP method stands for subjective,objective, assessment and patient care.One of the most common forms of documentation.Components of a thorough patient refusal document Complete assessmentevidence the patient is able to make a rational, informed decisiondiscussion with the patient as to what care/transportation EMS recommendsdiscussion with the patient as to what may happen if he or she does not allow care or transportation. Typically these consequences should be listed and clear to include the possibility of severe illness/injury or death if you care or transportation is refused.Discussion with family/friend/bystanders to try to encourage the patient to allow carediscussion with medical direction according to

local protocolproviding the patient with other alternatives:

going to see his or her family doctor, having a family member drive him or her to the hospitalwillingness of EMS

returning to patient changes his or her mindSignatures:

have a family member, police officer, or bystander sign the form as a witness. If the patient refuses to sign a refusal form, have a family member, police officer, or bystander sign the form verifying that the patient refused to sign. If the patient refuses care or did not allow a complete assessment, document that the patient did not allow for proper assessment and document whatever assessments were completed Patient care report (PCR)Prehospital care report, is the legal document used to record all aspects of the care your patient recieved, from initial dispatch to arrival at the hospital The following components should be included in your oral

report:

Patients name and the chief complaint, nature of the illness, or mechanism of injury.Detailed information, such as pertinent negatives and findings of a more detailed physical exam.Any medical history not already given.The patient's response to treatment given en route. It is especially important to report any changes in the patient's condition or the treatment provided after your radio report.Vital signs assessed during transport and up your radio report. Any other information that you obtained en route and after your radio report; for example, a list of medications that the patient is currently taking, or any known allergies to medications or food.How to write a narrative reportStandard precautionsScene safetyNOI/MOInumber of patientsadditional helpcervical spineinitial general

impressionlevel of consciousnesschief complaintlife threatsABC'soxygenprimary, secondary , patient history, or reassessmentSAMPLE/OPQRSTVital signsmedical directionmanagement of secondary injuries /treat for shockreceiving facilitytransfer of care

The narrative section of the PCR needs to include the

following information:

Time of eventsAssessment findingsemergency medical care providedchanges in the patient after treatmentobservations at the scenefinal patient dispositionRefusal of careStaff person who continued care