1. EMS Documentation

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

3. PCR Example

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

5. PCR Data Elements
Run Data
Patient Data
Check boxes
Narrative section

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

7. 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

8. 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

9. Check boxes
An efficient way to document parts of the call

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

11. Special Documentation
Patient Refusals
Confidentiality