EMS Documentation

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EMS Documentation
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Prehospital Care Report

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

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PCR Example
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PCR Functions

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

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PCR Data Elements

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

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Run data

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

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Patient data

• Patients 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

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Patient data cont.

• Signs and symptoms
• Baseline and subsequent vital signs
• SAMPLE
• Care administered and the effect on the patient
• Changes in condition throughout the call

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Check boxes

• An efficient way to document parts of the call

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Narrative

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

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Special Documentation

• Patient Refusals
• Confidentiality