EMS Documentation

EMS Documentation

Prehospital Care Report • The record that you produce during a call • PCR • Computerized Reports • Written Reports • Direct Data Entry

PCR Example

PCR Functions • Patient Care Record • Legal Document • Administrative Purposes • Education and Research • Quality Improvement

PCR Data Elements • Run Data • Patient Data • Check boxes • Narrative section

Run data • Agency name • Unit number • Date • Times • Run or call number • Crew members’ names, licensure levels, and numbers

Patient data • Patient’s name, address, date of birth, age, sex • Billing and insurance info • Nature of call • MOI • Location where patient was found • Tx administered before EMT arrival

Patient data con’t. • Signs and symptoms • Baseline and subsequent vital signs • SAMPLE • Care administered and the effect on the patient • Changes in condition throughout the call

Check boxes • An efficient way to document parts of the call

Narrative • Less structured • Provides space to write info about the patient that cannot fit into other sections • Should “paint a picture”

Special Documentation • Patient Refusals • Confidentiality

EMS Documentation