EMS Documentation

Prehospital Care Report

The record that you produce during a call

PCR Computerized Reports Written Reports Direct Data Entry

PCR Example

PCR Functions

Patient Care Record Legal Document Administrative Purposes Education and Research Quality Improvement

PCR Data Elements Run Data Patient Data Check boxes Narrative section

Run data

Agency name Unit number Date Times Run or call number Crew members’ names, licensure

levels, and numbers

Patient data

Patient’s 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

Patient data con’t.

Signs and symptoms Baseline and subsequent vital signs SAMPLE Care administered and the effect on

the patient Changes in condition throughout the

call

Check boxes

An efficient way to document parts of the call

Narrative

Less structured Provides space to write info about the

patient that cannot fit into other sections

Should “paint a picture”

Special Documentation

Patient Refusals Confidentiality