Transcript PCR In-service Version 2

PCR In-service
For NYS Version 5 PCRs
What is a Patient Care Report?
• Patient Care Reports
(PCRs) are legal
documents which are
used to record
pertinent health
information about prehospital patients.
What is a PCR?
• A PCR is a three part document printed on noncarbon copy paper, attached at the top.
• Three parts are usually referred to as ‘white’,
‘yellow’ and ‘pink’
• The ‘White’ copy is retained by your EMS agency for 6 years,
or 3 years past the patient’s 18th birthday; whichever is first.
• The ‘Pink’ copy is turned over to transporting agency, or to
the hospital.
• ‘Yellow’ copies are sent monthly to the Office of Prehospital
Care, and later to the State Department of Health for
research.
Why do we have to use PCRs?
Ambulance Services and ILS/ALS level agencies are
required by public health law to use the
New York State PCR
NYS Public Health Law, Article 30:
• “…ALS and Ambulance services, registered or
certified pursuant to Article 30 of this chapter shall
submit detailed individual call reports on a form to
be provided by the Department”
Why are PCRs important?
• PCRs are legal documents
• PCRs protect responders by serving as a legal record of
patient interaction
• Can be subpoenaed in legal proceedings
• PCRs help patient care
• Provide a record of care provided for a patient, so that
treatments are not duplicated, and can be expanded upon
during the full course of patient treatment
• PCRs are used for research
• PCRs are used in statistical research to identify strengths
and weaknesses in the EMS system, with the goal of
improving patient care across New York State.
When should I use a PCR?
• PCRs should be completed each time your agency is
dispatched for ANY response when EMS may be
needed:
– All patient transports
– All patient refusals
– Any time there is contact with a patient
– Certain calls when no patient contact is made:
• Call cancelled before reaching the scene
• Call when no patient is located
• Stand-by events
» There must be one PCR specifically for the stand-by and
additional PCRs for any treated patients.
Multi Agency Response
• When more than one agency responds to a scene, each
service should complete a separate PCR.
• Each PCR should reflect only the actions taken by that
crew.
Before we start….
• Use black ink for PCRs
• Fill in the circles completely, do not place ‘X’ or check
marks in the boxes
A circle
Should be filled in
like this
Not this
Call Received as
EMERGENCY
NON EMERGENCY
X STANDBY
Before we start….
• Use Military time (24 hour clock)
• Be careful not to write on top of other PCRs, the
writing will be transferred through the copy
paper to unintended copies.
• Write legibly!
You pull up on scene, and see:
You are responding with the fire department, and your Chief assigns you and your crew to take
care of the driver of the green SUV, who is outside of his vehicle, walking around. This training
is based on your assessment of this patient and documentation as a First Responder.
• Date of call
0 3 3 1 0 8
• Enter date that the call is
initially dispatched on
• Run number
0 0 2 5 4 1
• Enter the number that is
assigned by your dispatcher
or agency. Depending on
your system, you may not
receive this until after the call.
• Agency Code
0 0 1 4 9 0
• Enter the number that is
assigned to your agency by
New York State Department
of Health Bureau of EMS
• Vehicle ID
0 0 0 3 2 2
• Enter the identification
number of the vehicle that
responds to the call
AGENCY NAME XYZ EMS Agency
DISPATCH INFORMATION Minor injury Motor Vehicle Accident
CALL LOCATION Harlem Rd and Cleveland Rd
• Agency Name
• Insert the name of your EMS Agency
• Dispatch Information
• Insert the nature of the call as it was dispatched
• Call Location
• Insert the location of the call by address, intersection, or highway
mile marker
•
Location Code
• Enter the four digit municipality code for the
municipality in which the call takes place.
14 55
•
Location Type
• Residence:
» Private homes, multiple occupancies (ex.
Apartments, dormitories, etc)
• Health:
» A place where medical care is routinely
provided
• Farm:
» A rural place where agricultural products or
livestock are raised
Industrial
Other Work
Recreational
• Industrial
» A place where a product is manufactured or
stored
• Other work
» A place of work other than industrial facility (ex.
Offices)
• Recreational
» Places organized for recreation or sport, but
excluding homes and industrial places
• Roadway
» A place that is designated as a thoroughfare for
motor vehicles. Not a private residence
driveway
• Other
» Any other place that does not fit into any of the
above categories
Call Received as
Fill the circle of how the call was
received from the dispatcher
• EMERGENCY:
» Call dispatched as an emergency,
or potential emergency. This box
should include any emergency or
critical care transfers
• NON EMERGENCY:
» Routine calls such as non urgent, or
scheduled transports or transfers
• STANDBY:
» Unit dispatched but no patient is
treated such as when covering a
special event, standing by at a fire
or covering another station for
mutual aid.
Patient Information
John
Smi t h
123
Mai n
St
716
Akr on
40
NY
0 1
22
1968
12 3
123
4567
1 4001
45
6789
• Name:
» Enter patient name, if unknown write either “John Doe” or “Jane Doe”. If no patient, write
“No patient”
• Address:
» Write patient address, if unknown, write ‘unknown’
• Age:
» Enter age of patient. Age must be entered, regardless if DOB is present. If age is unknown,
enter approximate age. If the patient is less than one year of age, enter either ‘H’ for hours,
‘D’ for days, or ‘M’ for months. (ex. 7 months entered as ‘7M’)
• Date of Birth
» Enter the patient’s date of birth, if unknown, enter zeroes.
• Social Security Number
» Enter the patient’s Social Security Number, if unknown, write ‘000-00-0000’
Physician:
Enter name of patients primary doctor, if possible
Dr. Strangelove
Care in Progress on Arrival
Indicate the type of care, if any, the patient received prior to
your arrival. Indicate what was done for the patient
during this time in the comment section.
• None: The patient is not receiving any care
• Citizen: Care is being administered by an individual without any
level of EMS certification
• PD/FD/Other First Responder: Care is being administered by a
member of a Police or Fire Department or another certified First
Responder
• Other EMS: Patient is being cared for by a Physician, Nurse, EMT
or Paramedic (may be off duty)
• PAD used: The patient was defibrillated using a Public Access
Defibrillator
Mechanism of Injury
• Fill the appropriate circle
as to how the injury
occurred
• If the call is of a medical
nature, fill in the last
circle and write ‘Medical’
in the space provided
• Extrication required:
• Fill the circle if the patient needed to be extricated
• This applies to any situation when extraordinary measures
needed to be taken to prepare a patient for
treatment/transport
• Fill in the blank with the approximate duration of extrication
efforts, from on scene time, until the patient is free from
entanglement
• Seat belt used:
• Fill the appropriate circles for any patient involved in a
motor vehicle accident, and indicate who gave this
information
Chief Complaint
“My neck hurts”
• Record the patient’s chief complaint in their own words
» Ex. “I’m having chest pain”
• If the patient is unable to unwilling to offer a chief complaint,
state that the patient is unable to offer a chief complaint at
this time.
Subjective Assessment:
What the patient, family or bystander says
Pt states he was driving when he was struck from behind, sending his car up into the air. Pt
states he did not lose consciousness, but had a sharp 7/10 pain in his neck. He denies airbag deployment. He states was
able to open the door and get himself out of the car prior to our arrival. Patient denies chest pain, SOB, or back pain.
• An elaboration of the patient’s Chief Complaint, based on the
history obtained by the provider from the patient.
• If the patient cannot speak, then obtain from family or
bystanders, and indicate the source of information
Presenting Problem
Neck
• Fill in the appropriate circle to indicate the patient’s
presenting problem.
• If there is more than one, fill in all the appropriate circle, and
place a large circle around the primary problem
Past Medical History
• List patient allergies.
» If none, write ‘No
Known Allergy’, or
‘NKA’ in the space
provided
• Fill in all appropriate circles,
and list additional medical
problems
• List medications in the space
provided
• If more space is needed,
continue to the comments
section or continuation form
NKA
Metoprolol 50mg
b.i.d., Albuterol
prn
Vital Signs
07 25
20
07 36
18
104
90
138
92
15
134
86
15
• Vital Signs
• Enter each set of vital signs in the
space provided, if more than three sets
are obtained, use the comment section
or a continuation form.
• Always attempt to get two sets of vitals
in order to establish if a trend is present
(ex. decreasing blood pressure)
• Be sure that a time is entered
Objective Assessment:
What you observe
PE: ♂ in apparent distress, holding his neck. Pt CAOx3, no JVD or tracheal deviation present,
no deformities to neck, equal chest expansion bilat, with clear lung sounds, ABD-SNTx4, pelvis-stable, good PMSx4,
strong equal grips bilat., patient presents without neurological deficit, no other injuries or complaints found throughout.
Pt ambulatory PTA  primary eval  manual c-spine held  secondary eval  c-collar applied  vitals 
standing takedownbackboardstretchervitalspt turned over to Rural/Metro 555 for transport to St Joes.
• Objective Physical Assessment
• Enter in this section a summary of the primary and secondary assessment of
the patient.
• This should be a complete head to toe assessment
• You don’t have to repeat the same information that you filled out a circle for
above, unless it changes
• Comments
• Use this section for information which is pertinent, but does not fit in any
other section
» Includes: medication list, additional sets of vital signs, continued physical
assessment, etc.
• At the end of your narrative, insert initials to signify that the statement is
complete.
Treatment given
In this section, mark all treatments given by your agency.
» If treatments were performed prior to your arrival,
indicate this in the comments section
» Do not mark treatments performed by another agency
Turned over to RMA 555 for transport to St Joes
0 0 4
• Disposition
– If your unit transported the patient to the hospital, nursing home, or
other medical facility, enter name of such facility.
• If your unit transported the patient to the hospital, also include the reason for
transport (ex: ‘closest facility’, ‘patient choice’, ‘trauma center’)
– When these do not apply, enter the phrase from the ‘Disposition Code’
list found on the back of the PCR that best describes the call outcome.
• Disposition Code
– Enter the code number for the hospital transported to, or from the back
of the PCR.
Crew Members
S. Wander
C. Fenar
1 1 0 3 4 6
3 1 0 8 1 8
E. Bordonaro
2 2 5 6 4 9
A. Major
0 0 0 0 0 0
Enter the names of the crew members.
» The crew member in charge of the patient must be entered
in the first box; the driver’s name should be entered in the
second box.
» When the crew member is certified at any level, fill in the
circle corresponding to their current certification level, and
enter their six digit NYS certification number.
» If the person is not NYS certified, enter the individual’s
name, and fill the boxes with zeroes
Required Elements
When cancelled prior to arrival on scene
•
•
•
•
•
•
•
•
Date of call,
Agency Code,
Vehicle ID,
Dispatch information,
Agency Name,
Call Location,
Location Code,
Social Security Number (filled
in with 000-00-0000)
•Dispatch information,
•Type of call (Emergency/NonEmergency/Stand-by),
•Time call received,
•Time service responded,
•Disposition and disposition code,
•Crew names, level of certification and
number.
Required Elements
When ANY patient contact occurs
•
•
•
•
•
•
•
•
•
Date of call,
Agency Code,
Vehicle ID,
Dispatch information,
Agency Name,
Call Location,
Location Code,
Dispatch information,
Type of call (Emergency/NonEmergency/Stand-by),
• Time call received,
• Time service responded,
• Disposition and disposition
code,
•Patient Name,
•Patient Date of Birth,
•Patient Gender,
•Social Security Number
•Presenting problem,
•Vital signs if a patient was indicated
on the form,
•Chief Complaint,
•Subjective Assessment,
•Objective Physical Assessment,
•Past Medical History,
•All treatment provided by your agency
•Crew names, level of certification and
NYS certification number
Required Elements
When patient refuses transport
Same as when any patient contact occurs, PLUS
a WREMAC approved refusal form MUST be
utilized
Remember…
• Write only what your agency did
• Zeroes in any boxes that are left blank or if the
answer is unknown
• Horizontal lines across any section left blank
• Use only approved abbreviations
Remember…
• Subjective is what the patient Says
• Objective is what you Observe
• Mistakes should have one line through it, and it
should be initialed.
• Initial at the end of your narrative statement – do
not draw lines or scribble across the remaining
space
Questions/Comments?
• Department of Health PCR Policy Statement
• Feel free to contact the Office of Prehospital Care at
(716) 898-3600 or...
• Bill Major, Program Coordinator
» [email protected]
• Beth Bordonaro, PCR Specialist
» [email protected]
• Thanks to Cleveland Hill Fire Department for the MVC
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