DOCUMENTATION
OF THE PATIENT
CARE REPORT*
Policy:
An EMS patient care report form (PCR) will be
completed accurately and legibly to reflect the patient assessment, patient care
and interactions between EMS and the patient, for each patient contact which
results in some assessment component.
Purpose:
To document:
·
The total patient care provided including:
(a) System data regarding the EMS systems
response
(b) Dispatch information regarding the
dispatch complaint, and EMD card number
(c) Care provided prior to EMS arrival
(d) Exam of the patient as required by
each specific complaint based protocol
(e) Past medical history, medications,
allergies, living will / DNR, and personal MD
(f) All times related to the event
(g) All procedures and their associated
time
(h) All medications administered with
their associated time
(i) Disposition and / or transport
information
(j) All communication with medical control
(k) Signature of technicians providing
care
(l) Signature of treatment authorization
if any deviation from protocol
(m) Signature of receiving individual
assuming patient care at the medical facility
·
Reason
for inability to complete or document any above item.
Procedure:
1.
The
patient care report should be completed as soon as possible after the time of
the patient encounter.
2.
All
patient interactions are to be recorded on the patient care report form or the
disposition form (if refusing care).
3.
The
patient care report form must be completed with the above information.
4.
A
copy of the patient care report form should be provided to the receiving medical
facility.
5.
A
copy of the patient care report form is to be filed at the EMS office.