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