Transcript PCR writing PPT

Pre-Hospital Care Reports
A Quality Improvement Program
Karl W. Klug, B.S., EMT-CC
Deputy Chief of Operations
Suffolk County EMS
Remember when?
Patchogue, please
report to Triage with
your patient….
Brookhaven out.
Leah, did you
fill out a PCR
on that guy?
Ummm, no
Ron, I thought
you were
going to…
What’s the PCR’s Purpose?
Statewide data collection system
 Serves as a confidential and legal medical
record
 Quality Improvement instrument
 Standardized format for all providers
 Instrument to provide continuity of care
between prehospital and hospital settings
 Recently revised as Version 5 (2/04)

Housekeeping Rules


NYS-DOH states
agencies need to have
written policy dictating
guidelines for
completion, storage,
access, and release of
PCRs
Medical Records can
only be released on
certain conditions
(more later!!!)
When should a PCR be
completed?

One PCR for:
–
–
–
–
–
–
–

Every patient on every call
Treated by one unit transported by another (004)
RMA w/ informed consent (005)
Call canceled (006)
Stand-by only (007)
No patient found (008)
Every event i.e. Lift assist … (010)
To document every request for EMS that your agency receives,
whether you handle the call, or not, or whether there is a patient
or not
Other Response

A PCR is to be generated for every request
for ambulance response
Call canceled enroute by PD, MedCom, or chief
No crew shows up and you 24 the call
Fire standbys for the local FD
Ambulance response to fires within your own
FD
Who gets which copy?
– WHITE (original) retained by the EMS agency
– PINK stays with the patient in the emergency
department
– YELLOW is forwarded to Medical Control
For screening, local quality improvement, and submission to
Statewide data processing

May be exceptions for regionally-approved studies, i.e. intubation
confirmation, AED use, etc…
What about “No Transports”?
DOA or Field Discontinuance of
Prehospital Resuscitation
 Cancelled while enroute by PD / Chief
 Unfounded
 RMA
 Treated but refused transport
 Stand-by

What about “No Transports?”

On “no transports” the Agency is responsible
to mail the yellow copy to Medical Control by
the 20th of EVERY month
Tiered Response

For every patient, for every leg of the
trip
From same agency = 1 PCR
NYS DOH 02-05 (supersedes 93-05 and 85-01)
 When flycar arrives at scene before ambulance –
in old BLS manual, has been changed

From different agencies = 2 PCR’s

Each documents only what their service did
PCR’s are.......
 Medical
Records - Permanent part of the
patients chart
 Legal
Documents - Proof of your assessment
and treatment
 Standardized
Records - Statistical collection of
Statewide information
Confidentiality

The form and information contained on
the form is confidential

EMS providers have a legal obligation
to protect the confidentiality of patients

EMS Providers must comply with new
federal HIPAA requirements
HIPAA


Promulgated in 1996, Compliance effective
April 14, 2003.
Covered entities include
– All providers of health care services
– billing clearinghouses
– insurance plans

Effects our
– PCR retention schedule
– use of PHI as part of the QI process
– release of PHI that you collect
The PCR should be a
reflection of...

Assessment of
patient and
scene

Care rendered
by crew
And should include...

Pertinent +/- findings

Interventions

Changes in status

Response to those changes
And should include...

OPQRST

SAMPLE

All Vital Signs

Head-to-toe exam, vectored when appropriate
SOAP




Subjective: what the
patient tells you, history
of the present illness
Objective: P/E, +/findings
Assessment: prehospital
impression and
differentials
Plan of treatment: what
you did and the patient’s
response to the treatment
What To Write
 Chief
Complaint - in the patients own words
 Subjective Assessment - history of present
illness
 events leading up to..., secondary complaints, MOI
 Presenting
Problem - simple check-box format
 PMH/Meds/Allergy - document all pertinent
history
 be aware of heart/lung disease, diabetes, seizure
What To Write
 Objective
Physical Exam - Systematic
approach, cover all body areas and
don’t forget pertinent negatives
How you found the patient, what problems
you found, what you did to fix the
problem, and the response to your efforts
to fix the problem
What To Write
 Treatment
Given - simple check-box format
 Continuation Form for ALS suggested but not required (with
the exception of controlled substances)
 Disposition
 Crew
- Don’t forget the code
- Names and State EMT numbers only!
Badge/member numbers are UNACCEPTABLE!
Why The Need For A
Comprehensive PCR?
 Enhance
patient care
 Enhance
your position as a health care
professional
 Ensure
that your EMS agency has satisfactory
legal evidence documenting the response
Limit Your Liability





September 2002- EMS crew in New Jersey
transported a patient to local ED after suffering a
blow to his head
Hospital discharged patient after concluding that
injury was not serious
Patient developed seizures, became comatose and
was declared brain dead 4 days later and died
ER Physician stated he “would have ordered CT scan
if [he] knew patient had vomited”
EMTs were found to be negligent and liable for
wrongful death for FAILING to document
prehospital episodes of vomiting
Writing Styles

Divergent
– Takes into account all aspects of a complex
situation
Patient fell down a 30 foot embankment with multiple
injuries

Convergent
– Focus on the most important aspects of the
situation
Patient is apneic with a pulse
What about ALS calls?

Pre-Hospital Care Report Continuation
Form
– Anytime a medication is administered, the
Continuation Form should be used
– Controlled Substances require the use of the
Continuation Form
What about Albuterol and
Epinephrine?
EMTs may administer nebulized
Albuterol and Epinephrine via autoejector; the administration of these
drugs must be documented on the PCR
 Patient-assisted medications (i.e.
nitroglycerin and/or bronchodilators) must
be documented on the PCR

NY State Trauma PCR
For all patients who’s
presenting complaint
is traumatic in nature,
regardless of severity
or cause, and
regardless of whether
or not the patient is
transported to a
trauma center.
(some still around…data points
captured in RescueNet
TabletPCR)
Yep…I’m braggin’ here !

Good documentation
may protect everyone

Poor documentation
protects no one
Which would you rather
have on the stand
with you?
What About Mistakes?
 Change
on all copies
- strike with line and
initial
OR
 Re-write and
destroy white and
pink copies; retain
yellow copy, void it
and submit to
Medical Control
Who should have access to
completed PCRs?







Agency officers
QA Committee
Training Coordinators
System/Service Medical Director
NY State EMS Representative
Other Agencies that participated on the call
Patients / Legal Guardians of Patients
Medical Record

As a Medical Record, PCRs should only be
released when presented with a:
– Subpoena
– Medical release form signed by the patient, guardian, or
estate (for legal purposes)
– When requested by a patient or legal guardian (routine
purposes)
– EMS Division QI follow-up request
Legal Record

As a Legal record, all PCRs should be
completed before :
* Copies are separated
* Leaving the receiving hospital
Lets Clear Up the RMA Issue
In the event that an ambulance is dispatched to call where both
individuals at the scene and EMS personnel believe that no injuries
exist and that there are no individuals requiring or requesting EMS
assistance, the appropriate PCR code 008 (gone on arrival) or 009
(unfounded) shall be used. An RMA signature is not required, but
may be obtained if desired. A PCR, however must be completed. A
physical assessment may be necessary to make a “no patient”
decision. Also, remember to consider High-Risk Criteria before
making a “no patient” found decision.
If in the judgment of EMS personnel there is a patient at the scene
who requires treatment and/or ambulance transport, but refuses,
Medical Control must be contacted in an attempt to convince the
patient to permit appropriate care.
Lets Clear Up the RMA Issue
In the event that a patient receives treatment, but refuses transport by
ambulance, and the EMS provider agrees that ambulance
transportation is not warranted, then medical control need not be
contacted. This becomes a “treat and release”, or a “refuses further
medical assistance.” This decision and any recommended follow-up
should be noted on the PCR and an RMA signature obtained.
In the event that the EMS provider believes that ambulance transport
is indicated, Medical Control must be contacted.
Review of High-Risk Criteria
 Altered
Mental Status or suspected head injury
 Glasgow Coma Scale less than 15
 Less than 18 or older than 70
 Neurological, cardiac, or respiratory signs and
symptoms
 Abnormal vital signs
 Alcohol or drug use
 CO exposure
 NO RADIO CONTACT FOR RMAs
Bottom Line

Very few situations turn out to be
“unfounded”
– If all parties neither require nor requested EMS
and there is no mechanism of injury
– Inadvertent personal / home medical alert alarms

There are no protocols or procedures in NY
State that allow for EMS provider-initiated
refusals
– Your duty to act begins when you accept the 911
call
Common Weaknesses

No record of patient status after treatment given

Focused assessment does not match presenting
problem

No Documentation for reasons something can’t be
done
Common Weaknesses

Pertinent negatives omitted

Incomplete physical examinations

Lack of Repeat Vital Signs, when indicated

Use of non-standard medical abbreviations
Some Beauties…
Spontaneous Idiopathic Fernoquadriplegia or
Spontaneous Idiopathic Strykerquadriplegia: The
condition in which the patient suddenly develops
total body paralysis while transferring them from
your Ferno or Stryker stretcher onto the hospital
bed (usually affects patients over 350 lbs).
 Economically Challenged Urban Outdoorsman –
politically correct term for a homeless person
 Gravity Storms – causes of a rash of falls and fallrelated injuries

More Beauties…
Anti-Gravity Storms - The cause of accidents with
ejections
 NKDA – Not Known, Didn’t Ask
 Vitals WNL – We Never Looked
 TMB – Too Many Birthdays
 ART – Assuming Room Temperature
 CTD – Circling the Drain
 Just Kidding!!!

Common Omissions

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Date
Agency Code
Type of Alarm
Response Times
Presenting Problem
EMT Number
Location Code (Geocode)
SSN - Last 4 digits only vs
0000 or all 9 digits
Rejected PCRS





Will be returned to you
for completion
May inhibit your
QA/QI efforts
Increases liability
Agency does not
receive credit for
number of responses
Reduced future
delivery of PCRs
Karl’s Pet Peeves
“Sluggish
Pupils” (is that before or after algebra?)
 Measuring the depth of lacerations (hopefully that
ruler is BBP compliant!)
Using the dispatch data as the chief complaint
(I didn’t think the person said “I’m having an MVA”)
The
term “neuro deficit” (were you able to measure that?)
The A&O x 3 scale (wasn’t that a Railroad in Monopoly?)
If you use a medical word - know what it means
and how to spell it (hey- Anna Falaxis, is that you?)
Yes, I actually saw these...




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


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John Dow
Posed Dictal
Sinkable
Groinal Area
Consous
Reveils
Difrederick
Antiobiodack
Glue Coast
Please
help me...
Helpful Hints
Your PCR should be like a math problem…..

Subjective Interview
+

Objective Examination

=Treatment Plan
Prehospital
Impression
Interventions
Response
Helpful Hints

If you want to do it, and the patient doesn’t
let you - tell them why they need it, and what
may happen if you don’t do it - and
DOCUMENT IT AND GET A SIGNATURE

If the protocol calls for it and the patient
doesn’t want it - tell them why they need it,
and what may happen if you don’t do it - and
DOCUMENT IT AND GET A SIGNATURE
Helpful Hints

If the protocol says you need to do it and you can’t do it - DOCUMENT IT on
the PCR.
Supporting Documentation

Public Health Law Article 30

NYCRR Part 800.21

NY State EMS Policy Statement 02-05

Suffolk County Operations Policy 2-001
What about changes after the
PCR is submitted?



Complete an
addendum for the
original record
NEVER alter the
original service copy
Provide copy of
changes to hospital
and State for their
records
Let’s Look at a Few PCRs…
(The Good, The Bad, and The Ugly)
The Good…
The Ugly…
OK…What’s this HIPAA stuff
everyone’s talking about?
HIPAA and PCRs

Health Insurance Portability &
Accountability Act
– Enacted in 1996
– Full compliance by all health care entities
(can you say EMS?) REQUIRED by April
14, 2003
HIPAA and PCRs

Regulations affect ambulance and first
response services in three specific areas:
– PCR Retention Schedule
– Utilization of protected health information
as part of your agency’s QA/QI program
– Release of protected information your
agency collects on a PCR to a patient
PCR Retention Schedule

NYS-DOH Policy
Statement 02-05
– Keep white copy 6
years, or 3 years past
a patient’s 18th
birthday, whichever
is longer

SCEMS Policy
Statement 1-010 and
2-001
How Long Do We Keep
Them?




Must be kept in a
secure location
6 years (HIPAA)
3 years from the child’s
18th. Birthday, or 6
years, whichever is
longer
5 years if Controlled
Substances were used
PCRs and QA
 EMS agencies are encouraged to use
PCRs as part of their QA/QI efforts
 ALL personal indicators on the PCR
must be eliminated
 “Blacked out” name, address, date of
birth and call location remains
acceptable when distributing copies to
QA Committee for review
Release of Information


Faxed copies OK;
must ensure
recipient received
Release form signed
by patient or by
attorney on behalf of
patient
– In person with ID
– Keep record of all
releases

PCRs may be
released to:
– NYS-DOH
employee as part of
inspection
– EMS Medical
Director or designee
– Countywide QI
process
– In response to Notice
of Claim
Where Can I Get Help?

New York State DOHBureau of EMS
– EMS Agency Operational
Resource Guide


Section 8 – Instruction
Manual for Prehospital
Care Report
Suffolk County EMS
Operations Manual
Any Questions ?