Essential EMS Training Program – Block 1 PCR Form Essential EMS Training Program – Block 1

Topics for Discussion EMTs provide essential care for patients during transport Documenting this care is critical Principles / Purpose EMS Documentation Roles of Documentation (why) PCR Report for Cambodia Evaluation for Completeness Open the discussion by discussing the role of documentation in patient care. Any healthcare provider that provides care to a patient must document the care in the patients chart or record. The patient care report is the document that is used to accomplish documentation of care received outside of the hospital.

Documentation is Important Improves patient care Allows data to be collected for research and quality improvement. Provides a lasting record of care provided. Provides data to government to identify key medical issues. Documentation is important for all of the above reasons. Without a way to record this information, any data about patient care provided outside the hospital would only be speculative and not really be reliable for making decisions on.

Importance of PCR Written record of the incident Legal record of the incident Provides information about the incident to other medical professionals. Valuable for quality improvement Provides information for Hospital Administration Provides data to the government. All of these points are self explanatory. Initially as the process to gain the information from the PCR begins the data will not be complete. However as the years pass, and more data is compiled the PHD’s and other government staff will be able to track trends and have enough information to make decisions.

Administrative Uses Provides information about the patient for MDs and Administrators Provides information about where patients are arriving from. Provides information about transfers to other facilities. Hospital Administrators and PHD’s both have a need for patient care information and especially inter-facility transports so they can make good decisions about asset allocations in the province.

Record of the Incident It is the only permanent factual record about what happened. It should record information about the call from beginning to end. It provides a source of information for others who later need to know about it. Memories fade quickly. The patient care report is attached to the patient record and should be retained for many years. Once the data is compiled and reported to the PHD and the MOH the data becomes part of the historical data set used to establish trends and track effectiveness of programs to reduce trauma in the community

Legal Record PCR can be used to help clarify legal issues. Many people need to know about the incidents, especially road accidents. Insurance companies Police Government There are others in the community that often need to see the patient care report. The police and commune officials often have reports and documentation they need to file which the PCR can give information to. Insurance companies also require documentation about accidents and injuries before they can pay claims for their insured clients.

Medical Professionals Pre-hospital ambulance care can affect the patients recovery. Care given on the scene can improve or save a patients life. Scene events may change how a doctor treats a patient. The most obvious group interested in receiving the patient care report is the physicians and nurses. The patient care report (PCR) often gives information about the patients care or condition given during transport outside of the hospital. This information is important as that the patient receives a good level of care during their hospitalization.

Quality Improvement Gives objective information for MDs and administrators to use to improve patient care. Provides long-term data to show improvements. Helps decide who gets money for projects. Improvement of patient care is the goal of all healthcare providers. In order to improve services, you must have documentation of the baseline data so that changes can be compared as measured from that point. The patient care report gives MD’s and hospital Administrators the data needed to measure ambulance patient volumes', transfer patterns, community illnesses and trauma types and much more data.

Data for Government Identifies locations for safety improvements including time of day the accidents occur. Provides data to improve patient care including transfer patterns. Provides data to identify medical issues that must be addressed. As the government funding pool grows, data is necessary for making decisions about where the funding will be spent. Documentation of frequent accident locations or other unsafe conditions will make funding for corrective conditions much easier to accomplish with supportive data.

PCR Formats Basic form is hand written Computer based Tablet based iPhone or Android based There are several formats for the PCR used around the world. The paper hand written form is where every system starts. This provides for obtaining the basic information and establishes the internal process for obtaining the information. The paper system is simple and sustainable. The down side is getting the data collected from the paper forms. As funding becomes available, many EMS providers will switch to digital gathering and reporting of data, which makes the data available immediately as soon as the EMT enters it. This kind of system takes time to develop and sustain but in a digital age is the inevitable evolution of the system.

Hand-written form gathers pertinent data from each transport PCR Hand-written form gathers pertinent data from each transport This is a copy of the approved Ministry of Health Patient Care Report (PCR). This report is available from the Office of Preventative Medicine in the Ministry of Health.

PCR Key Points Must be completed after EVERY transport. Must be legible. Must be accurate. Must be signed. Key Points are that the Report must be completed on every call whether to the hospital or from one hospital to another. Each time a patient is placed into an ambulance and transported another report will be written and filed.

Computer Format Benefits Ease of data collection and merging Decrease in errors Obstacles Cost Technology can be unreliable This slide is only to show that we are aware that it is possible to collect this information on a computer. In the future as the ambulance industry here matures, this kind of technology can be introduced.

Cell Phone Systems Benefits: Inexpensive, widely available Can send data over cell system. Reliable Obstacles Technology changes quickly. Cannot handle large amounts of data. Most are personal devices. We put this slide up more to answer questions more than anything else. Cell phone systems do exist but they have not become widespread because of their limited data capacity and because the technology changes so rapidly. Cell phones are a possibility but have many technological problems to engineer through before they can become a viable work platform.

Times Record all requested times on PCR Use a 24 hour time format. Response time and scene time information is important. Use dispatch center times when available. We are not going to go through each line of the Patient Care Report and show you how to fill it out. Everyone in the class should be familiar with this process. There are two sections that usually get some questions. This section deals with times. All of the “times” are important for data collection. All are self explanatory. Time call received is the time that the ambulance or dispatch point is notified about the patient. Departure is the time the ambulance actually leaves the station and starts toward the patient. There will always be several minutes difference here. The arrival at the scene time is when the ambulance arrives where the patient is. Left the scene is when the ambulance actually begins to leave the scene and arrival at the hospital is when they arrive at the hospital.

Narrative Portion Additional information about the call should be recorded at bottom and on back of form. This part allows for a timeline of the call. It should include objective information (or things you observe). It should never include slang, biased statements, or personal opinions. The narrative portion is a part that some EMT’s use to record additional important information about a call. It is information that the EMT wants others to know that is not specifically requested in the check boxes. This information is helpful to the ED staff that is providing care to the patient and includes any information that the EMT would like to record about the event. Many countries (or service providers) prescribe a format for these types of recordings such as CHART or SOAP methodology but currently these are not part of this process.

Changes or Revisions Only the original author of a PCR can change it. Always date and initial any changes. Never white out or mark out original – only draw one line through the old information. These are significant points and apply to all medical documentation.

Practice Case Channa Din 22 year old female DOB: 6/6/1992 Phone 855 23 213 777 Address: Prey Kanlaong Incident location: Home Transfer to: Prey Veng Hospital Practice case should be completed with the practice PCR’s that should have been given to each student at the beginning of the module. Have them fill in the blanks as you work through the case study

Show the students where on the PCR the information goes Show the students where on the PCR the information goes. This is very straight forward and should not be a problem for anyone.

Special Considerations These issues are not being addressed in this training but eventually will be. Patient refusals No services needed Deviations from standard care Mass causality incidents Road deaths not transported All of these are issues that every EMS service will eventually need to consider. Currently the Ministry of Health does not specifically have policies to address these issues but some PHD”s have developed specific policies. The EMT will need to learn how the OD or PHD wants these issues handled. Eventually each of these will have a policy so that there is consistency in how the issues are handled.

Questions ??? Medics and ambulance should begin using the PCRs now. Plan is to train each Province and implement the program. Thank you for your desire to improve the healthcare for all of Cambodia. Most frequent question will be “when do we start to use these. The answer is NOW. We can supply these during the initial training but the instructor needs to find out where the supply of forms is located because it may vary by province. It is a national form but some provinces will keep a supply and some will get direct from Ministry of Health, Office of Preventative Health.