EMS Documentation - PowerPoint PPT Presentation

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EMS Documentation

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EMS Documentation Prehospital Care Report The record that you produce during a call PCR Computerized Reports Written Reports Direct Data Entry PCR Example PCR ... – PowerPoint PPT presentation

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Title: EMS Documentation


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
  • 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

8
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

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
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