What is the most common type of record that is prepared and submitted?
Prehospital care report (PCR)
Which three major goals should you complete when preparing your pcr?
- The information provided is essential in the continuation of care of the patient when she or he reaches the medical facility.
- Your PCR may be the only documentation you have to fall back on if it calls ever subjected to legal action.
- Reimbursement is often linked to the information provided in your p.C.R
A list of functions for the PCR
- it helps the receiving hospital better treat the patient
- it is also used for preparing bills, insurance companies and statistics.
- your documentation may have to be brought up for a legal court case and it will be your only alibi in such a situation / be evidence
- the PCR can also be used to identify issues and improve issues (statistics)
- the PCR can also be used for research (basically more statistics analysis)
Who has tried to standardize the information collected on p.C.Rs?
The Department of Transportation.
What is the minimum dataset?
The set of data the Department of Transportation recommends including all P.C.Rs
What is the administrative information?
Time the incident was reported
time the unit was notified.
time of arrival
time the unit left
time the unit arrived at the hospital
time of transfer of care.
What is the patient information?
Level of responsiveness,
B.P
skin perfusion, skin color temperature and condition
pulse rate
respiratory rate and effort
patient demographics.
Administrative information may ALSO include:
The e m s unit number and the run or call number
names of crew members and their levels of certification
the address to which the unit is dispatched
What other patient data must you collect?
The patient’s legal name, age, sex, race, and birthday.
The patient’s home address.
The insurance or billing information
The location where the patient was found
Any care given before the arrival of the EMTS
How many times should you record vitals in the pcr?
Twice. And make sure to also take note of patient’s position.
In the patient narrarative section of the pcr, what should you include?
The patient’s chief complaint, the patient’s history or mechnamism of injury. This information should be a mix of objective and subjective information.
What are pertinent negatives?
Science or symptoms that might be expected.But that the patient denies having.
All sections of the PCR (probably important!!)
-Always make sure to have the minimum data set.
- have the patient.
Information
- have the administrative information.
- patient demographics and other patient data.
- vital signs
- Patient narrative
- treatment.
Where are the PCR reports distributed?
- Kept by emergency services
- Copy Given to patient or receiving facility
- Third copy to medical oversight or quality improvement official
