PCR Inservice

Some date, 2009

Does this sound familiar?

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Why must we complete PCRs…
* legally required... Article 30, Section 3053
“…..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…..”

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A PCR is a legal document that transcribes
your findings and interventions.
Complete each PCR with the thought that it is a legal
document and that someday I may end up in court.
If a finding, an action or intervention is not
documented then it is generally recognized as
having not occurred.

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Where do PCRS go?

white original copy is retained by the EMS Service

pink copy is given to the transporting agency and

eventually to the receiving hospital

yellow research copy is forwarded monthly to Lake

Plains by the 10th of each month
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 EMS Service Copy (White)
 Patient record of prehospital care
 Protection for provider and service
 Internal QI
 Service medical director review

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Record
Keeping
PCRs must be maintained for 6 years!!

 If a person under 18 years of age is treated, the PCR

must be kept until the patient turns 21

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Patient Confidentiality
 PCRs must be encrypted to be used for QA/QI
 Date of call
 Run number
 Patient name, address, DOB, & physician
 Call location
 Crew names & certification #’s
 Only the crew may see the PCR in its entirety
without a subpoena
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HIPAA

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Hospital Copy (Pink)
 Transfer of patient information to hospital for continuity of care
and becomes part of the patient’s permanent medical record
 Hospital/agency/system joint QI
 Hospital record of call for exposure notification

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Lake Plains Copy (Yellow)
 Data is submitted to DOH for processing and entered
into a statewide database

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Lake Plains Copy (Yellow)

 PCRs are sent with a note that list

– Name of agency
– Agency code number
– Month
– Total number of PCRs being forwarded
 PCRs sent to:
Lake Plains Community Plains Network
56 Harvester Dr. Suite 1
Batavia, NY 14020 13
The Data Generation…

 Lake Plains scans for the following items.

PCRs are returned if any of the following
are missing.
– Date
– Patient name
– Agency name
– Location code
– Location circle
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The Data Generation…
– Date of birth
– Sex
– Social security number
– Call type (emergency vs. non-emergency)
– Presenting problem circle
– Disposition site and number
– EMT information and level circle

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COMPLETING THE PCR…

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When to use a PCR...
 All patient care, including cancelled, on
scene calls and refusal of medical
assistance calls
 Any situations which create a “Duty to
Act,” including cancelled enroute calls,
stand-bys, and non transport calls

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Multiple Unit/Agency Response

 When more than one agency responds to

a call, each agency must complete a
PCR

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Multiple Unit/Agency Response
(Continued)

 PCRs should only reflect the care rendered

by the specific unit
 All pink (hospital) copies of the PCR must
be given to the transporting unit
 Do not delay patient care and/or transport
to complete the PCR

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Mandatory Data Items
 Date of Call
 Call Times
 Call Type as Received
 Agency Code
 Location Code
 Disposition Info
 Crew Names & CFR/EMT #’s

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The following information MUST be entered:

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Location Code
 Mandatory data item
 Determined by location of the call, not the
patient’s home address
 Specific to each area by municipal
boundaries, not post-office zip codes (i.e..
village or town)

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Mechanism of Injury
 Fill in circles for appropriate cause of injury
 If the injury is not caused by an outside
agent, write “Medical”

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Chief Complaint
 Describes “IN THE PATIENT’S OWN
WORDS” if possible
 If the patient cannot speak, document why
the ambulance was called (must note who
gave this information)

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Presenting Problem
 Prehospital evaluation
classifying the presenting signs
and symptoms
 May be more than one item
 Prioritize multiple presenting
problems by circling the
primary medical issue

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Subjective Assessment
 Elaboration of the Chief Complaint based
on the history obtained by the provider
 Obtain from patient, or if patient can not
speak, from by-standers
 Document the source of information
 Document any language barriers

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Subjective Assessment
(Continued)

EXAMPLE:
* patient c/o substernal chest pain x 2 hours, occurred
while resting. Pain radiating to left arm and jaw. Pt.
denies relief after self administration of 3
Nitroglycerin x 15 minutes. Patient c/o nausea, but
did not vomit.

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Past Medical History
 Prior medical conditions (chronic/acute)
 Current medications/dosages
 Allergies (meds/foods/other)
 Note if patient denies past history
 Document source of information

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Vital Signs
 Minimum two (2) sets of complete vital signs
should be documented to monitor patient status
(i.e. deterioration/improvement)
 Document time of each set and reasons for delay
 Every 5 minutes for critical patients
 Every 10 – 15 minutes for non-critical patients
 For extended calls or seriously ill patients,
increase monitoring

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Vital Signs
(Continued)

 Blood Pressure:
 Must be taken with a blood-pressure cuff initially,

can be done by instrumentation thereafter. Compare

two readings to ensure accuracy.
 Make sure you complete each set of vital signs
once you have started them

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Objective Physical Assessment
 What you find during your initial and
detailed physical assessment
 Do not get carried away, include just the
facts that are relevant to the call
 You don’t have to repeat the same
information that you already checked off
in a box unless it changes

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Treatment Given
 Must fill in circles and fill in the blanks as
necessary for each item
 Use Comment Section or Continuation Form to
elaborate treatment if necessary
 Document only the care provided and/or directed
by your unit
 BLS units shall not document treatment provided by
ALS units

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Comment Section
 Use the Comment Section when you need
additional space for physical assessment,
comments or for other important
information, such as an unusual
circumstances, etc.
 Please use only approved NYSDOH
abbreviations

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Hospital Disposition Codes
 Hospital disposition codes are specific to
each facility/region
 Write the name of the hospital as well as its
disposition code
 Codes are mandatory data items

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Non Hospital Disposition Codes
* Nursing Home…001
* Other Medical Facility…002
* Residence…003
* Treated by this unit but transported by another…004
* Refused Medical Assistance…005
* Call cancelled…006
* Stand-by Only…007
* No patient found…008
* Other…010 37
Crew Names & EMT #’s
 Must be the technician’s last name & their New York State
DOH issued certification number, not a squad number
 If additional crew members (i.e. Driver) are not EMT/CFR
certified, print their last name and strike through the
number boxes
 Each PCR must have an EMT “In Charge”
 As of January 1, 2001, DOH requires a minimum of 1
EMT in the back of the ambulance for transporting
agencies

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Don’t forget the back...
 Non-Hospital Disposition codes
 Hospital Receiving Agent Signature
 Refusal of Treatment/Transportation
 Glascow Coma Scale
 Rule of Nines

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Continuation Forms
 Used when you have an extended call or unusual
circumstances requiring additional information
 Must be used whenever a medication is
administered
 Information must be documented in a sequential
fashion utilizing the assess, treat, reassess, treat
methodology

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Refusal Forms
 Fill out a PCR for every patient who
chooses to “sign off”

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PCR Corrections
 If the PCR is found to have an error, changes to
the PCR can be made by:
 Crossing out errors with a single line (the
errors must remain legible)
 Initial after each error
 Document reason for change
 Be sure that change is seen on all copies

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JUST REMEMBER…
CHART SOAP
 C – Chief complaint  S – subjective (What did the
 H – history pt. tell you?)
 A – assessment  O – objective (What did you
 R – response see?)
 T – treatment
 A – assessment (What did
you find?)
 P – planning (What are the
interventions?)

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In Summary
 Complete all areas of required information
 Document the events before, during, and after

each call; if it is not documented, it was not done

 Provide an accurate record of care provided
 Be concise, thorough and complete
 If you can not read it, it was not done

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Any Questions?