INSTRUCTION MANUAL FOR PREHOSPITAL CARE REPORT Show INTRODUCTION See NYS DOH Policies 02-05 and 03-03 (PDF file) An essential part of any prehospital medical care is the documentation of the care provided and the medical condition and history of the patient. The Prehospital Care Report (PCR), used as a requirement of Part 800, is the instrument developed and distributed for this documentation. The primary purpose of the PCR is to document all care and pertinent patient information as well as serving as a data collection tool. The documentation included on the PCR provides vital information, which may be necessary for continued care at the hospital. As part of transferring the patient to the Emergency Department Staff the agency should not leave the hospital until a completed PCR is provided to the appropriate hospital staff. PCR Use: A PCR should be completed each time the agency is dispatched for any type response. This includes (but is not limited to):
If an agency is dispatched to a stand-by and while there they treat a patient, two PCRs should becompleted. Information Entry: All information on the PCR should be legible and printed in black ink. Any member of the crew may enter information on the PCR. The individual indicated as "In Charge" should be the person who provided or directed the care to the patient. There is no requirement that the person in charge be certified as the highest level of care present. However the individual indicated as in charge is responsible for the care provided and documented. The provider listed as "In Charge" must be at least an EMT. If any advanced life support care was provided to the patient, the provider listed as "In Charge" must be an advanced EMT at the level appropriate for the care provided. On each PCR the following information must be entered:
Distribution: Pink (Hospital Patient Record) Copy:
Yellow (Research) Copy:
NOTE: There are agencies participating in projects submitting data directly to the Department of Health electronically. These are the only agencies exempted from this provision. White (Agency) Copy:
Confidentiality & Disclosure Of PCRs/Personal Healthcare Information: Maintaining confidentiality is an essential part of all medical care, including prehospital care. The confidentiality of personal health information (PHI) is covered by numerous state and federal statutes, Polices, Rules and Regulations, including the Health Insurance Portability & Accountability Act of 1996 (HIPAA) and 10 NYCRR. 10 NYCRR (Health) Part 800.21: Every person certified at any level pursuant to these regulations shall: (a) At all times maintain the confidentiality of information about the names, treatment, and conditions of patients treated except. (1) A prehospital care report shall be completed for each patient treated when acting as part of an organized prehospital emergency medical service, and a copy shall be provided to the hospital receiving the patient and to the authorized agent of the department for use in the State's quality assurance program; Health Insurance Portability & Accountability Act of 1996 (HIPAA): Federal Law (HIPAA) requires all healthcare providers to have a written policy on protecting Personal Health Information (PHI), including PCRs. Such a policy should include (but not be limited to):
Providing PCR copies to the receiving hospital, other providers giving care in a tiered system and to the EMS program agency for QI does not constitute a violation of the HIPAA regulations. For additional agency specific questions regarding HIPAA agencies should contact their legal counsel and/or the U.S. Department of Health and Human Services. Other PCR Disclosures: The PCR may also serve as a document called upon in legal proceedings relating to a person or an incident. No EMS agency is obligated to provide a copy of the PCR simply at the request of a law enforcement or other agency. If a copy of the PCR is being requested as part of an official investigation the requestor must produce either a subpoena, from a court having competent jurisdiction, or a signed release from the patient. Except that copies of PCRs must be made available for inspection to properly identified employees of the NYS Department of Health. A person may request a copy of a PCR completed for themselves as the patient or the parent or legal guardian of a patient may obtain a copy of a PCR completed for that patient. In cases where the patient is now deceased the person who is the court appointed legal representative of the patient's estate may request a copy of the PCR. An agency may provide a copy of a PCR to those entities that represent that agency either for the purpose of collection of fees from the patient or their insurance carrier or as part of any legal proceedings relating to the agency. In such situations those representative are also responsible for protecting the personal health information contained within the document. Disposition Codes: All hospitals in New York State have a three digit code indicting the hospital. In addition the name of the hospital must be indicated.
NOTE: It is impossible to include every possible scenario an effort is made to provide guidance on many common occurrences. Version 5 The Department of Health maintains a data system that tracks all inpatient care in hospitals by linking some of the data, Version-5 of the PCR will allow for the collection of additional data. That will allow linking prehospital patient care and the care provided by the emergency department and if admitted the hospital through to discharge. The linkage is obtained by certain identifying factors such as digits of the social security number and several of the characters in the patient's last name. This will permit the EMS system to better determine the effectiveness of the care given in a prehospital setting for quality assurance purposes. Version-5 also includes characteristics necessary to utilize this form as a scannable instrument. Optical Character Recognition (OCR) will permit the form to be scanned and have the data extracted from it into useable tables. The only way this will be accomplished is if the person completing the form prints legibly. This will allow agencies, counties or regions to consider scannable systems locally. Completing a Version-5 PCR: While the form looks different, all of the previous items contained in a PCR are continued on the Version-5. Several items have been added and the format that information is entered has also been changed. Added to the Version-5 are:
The other differences between Version-5 and the previous versions include: 1. Boxes are now provided for each character of agency and patient identifying information.
2. The Presenting Problem, Treatment Given and several other "Boxes" are now circles.
There are no special tools required to complete the PCR, however it must be completed using black ink to be read by a scanner. GENERAL INSTRUCTIONS The PCR is a three-part document printed on NCR paper. Each form is bonded at the top. Care must be taken that what is written on one PCR set does not come through on the set below (an aluminum form-holder clipboard is recommended). It is important that firm pressure with a ballpoint pen be used. Be as neat, complete and accurate as possible when completing this form. If a section does not apply to a particular call, leave it blank. Do NOT write NA or draw lines across sections of the form; this can cause scanning errors. It is important for the crew members to review the document before it is submitted. If an error is made prior to the PCR being submitted, enter the correct information on a second PCR and destroy all copies of the first form. MILITARY TIME Military time must be used for all time entries on the PCR. Military time can be easily calculated by adding 12 hours to any time after noon and before midnight. All military times are in four-digit form.
RED AREAS ON THE PCR Some areas of the PCR are printed in red. This is for scanning purposes, the scanner does not read red (please be sure you fill out the form with black or blue ink). THE BACK OF THE FORM Non-Hospital Disposition Codes: A listing of codes used other than state hospital codes. Hospital Receiving Agent: This section is available for those agencies required to obtain a signature from the hospital personnel receiving the patient. When used, open the form so that the signature is on the agency (white) copy only (if you do not open the form, the signature will not appear on your agency copy). Refusal of Treatment/Transportation Release: This section is provided for legal protection when a patient refuses treatment or transportation by your agency. When used, open the form* so that all entries are on the agency (white) copy only (if you do not open the form, the signature will not appear on your agency copy). Circle "treatment" and/or "transport to a hospital" and have the patient and the witness sign on the lines provided. The Rule of Nines: Figures are for your reference in assessing burn severity. Glasgow Coma Scale and Trauma Score: Guides are for your reference in completing the Vital Signs section of the PCR. ICD Diagnostic Code: for Hospital use only. Insurance Data: Enter the insurance information that your agency requires. *Any time you write on the back of one of the pages, you must open the form so that what is written does not destroy the data on the front of the page. What must be documented on a prehospital care report PCR?The documentation included on the PCR must indicate that the patient was advised of the need for care and the patient was competent to make an informed refusal of such care. Any time a call is canceled prior to the arrival of the EMS agency this disposition code should be used.
Which of the following is a function of a prehospital care report quizlet?What are main purposes of the prehospital care report? It serves as a record of patient care, as a legal document, provides information for administrative functions, aids education and research, and contributes to quality improvement.
Which of the following is not an appropriate way of dealing with a patient who does not speak the same language as you do?Which of the following is NOT an appropriate way of dealing with a patient who does not speak the same language as you do? Avoid communicating with the patient so there is no misunderstanding of your intentions.
What is a prehospital care report?(prē-hos'pi-tăl kār rĕ-pōrt') An electronic or written report completed by a prehospital provider that contains demographic and medical information as well as a record of the treatment and transport of a patient.
|