Pre-Hospital Care Pre-Hospital Care ReportsReports

A Quality Improvement A Quality Improvement ProgramProgram

Karl W. Klug, B.S., EMT-CC

Deputy Chief of Operations

Suffolk County EMS

Remember when?Remember when?Patchogue, please Patchogue, please report to Triage report to Triage with your with your patient….patient….Brookhaven out.Brookhaven out.

Leah, did Leah, did you fill out a you fill out a PCR on that PCR on that guy?guy?

Ummm, no Ummm, no Ron, I Ron, I

thought you thought you were going were going

to…to…

What’s the PCR’s What’s the PCR’s Purpose?Purpose?

Statewide data collection systemStatewide data collection system Serves as a confidential and legal Serves as a confidential and legal

medical recordmedical record Quality Improvement instrumentQuality Improvement instrument Standardized format for all providersStandardized format for all providers Instrument to provide continuity of care Instrument to provide continuity of care

between prehospital and hospital settingsbetween prehospital and hospital settings Recently revised as Version 5 (2/04)Recently revised as Version 5 (2/04)

Housekeeping RulesHousekeeping Rules

NYS-DOH states NYS-DOH states agencies need to agencies need to have written policy have written policy dictating guidelines dictating guidelines for completion, for completion, storage, access, and storage, access, and release of PCRsrelease of PCRs

Medical Records can Medical Records can only be released on only be released on certain conditions certain conditions (more later!!!)(more later!!!)

When should a PCR be When should a PCR be completed?completed?

One PCR for:One PCR for:– Every patient on every callEvery patient on every call– Treated by one unit transported by another (004)Treated by one unit transported by another (004)– RMA w/ informed consent (005)RMA w/ informed consent (005)– Call canceled (006)Call canceled (006)– Stand-by only (007)Stand-by only (007)– No patient found (008) No patient found (008) – Every event Every event i.e.i.e. Lift assist … (010) Lift assist … (010)

To document every request for EMS that your To document every request for EMS that your agency receives, whether you handle the call, or agency receives, whether you handle the call, or not, or whether there is a patient or notnot, or whether there is a patient or not

Other ResponseOther Response

A PCR is to be generated for every A PCR is to be generated for every request for ambulance responserequest for ambulance response Call canceled enroute by PD, MedCom, or Call canceled enroute by PD, MedCom, or

chiefchief No crew shows up and you 24 the callNo crew shows up and you 24 the call Fire standbys for the local FD Fire standbys for the local FD Ambulance response to fires within your Ambulance response to fires within your

own FDown FD

Who gets which copy?Who gets which copy?– WHITE (original) retained by the EMS agencyWHITE (original) retained by the EMS agency

– PINK stays with the patient in the emergency PINK stays with the patient in the emergency departmentdepartment

– YELLOW is forwarded to Medical ControlYELLOW is forwarded to Medical ControlFor screening, local quality improvement, and submission For screening, local quality improvement, and submission

to Statewide data processingto Statewide data processing

May be exceptions for regionally-approved studies, i.e. May be exceptions for regionally-approved studies, i.e. intubation confirmation, AED use, etc…intubation confirmation, AED use, etc…

What about “No What about “No Transports”?Transports”?

DOA or Field Discontinuance of DOA or Field Discontinuance of Prehospital ResuscitationPrehospital Resuscitation

Cancelled while enroute by PD / Cancelled while enroute by PD / ChiefChief

UnfoundedUnfounded RMARMA Treated but refused transportTreated but refused transport Stand-byStand-by

What about “No What about “No Transports?”Transports?”

On “no transports” the On “no transports” the Agency is Agency is responsible to mail the yellow copy to responsible to mail the yellow copy to Medical Control by the 20Medical Control by the 20thth of EVERY of EVERY month to:month to:

Stony Brook University Medical CenterStony Brook University Medical Center

Department of Emergency Medicine - Department of Emergency Medicine - EMSEMSSUNY at Stony BrookSUNY at Stony BrookStony Brook, New York 11794-8350Stony Brook, New York 11794-8350

Attn.: PCR InspectionAttn.: PCR Inspection

Tiered ResponseTiered Response

For every patient, for every leg of the For every patient, for every leg of the triptrip

From same agency = 1 PCRFrom same agency = 1 PCR NYS DOH 02-05 (supersedes 93-05 and 85-01)NYS DOH 02-05 (supersedes 93-05 and 85-01) When flycar arrives at scene When flycar arrives at scene beforebefore

ambulance –in old BLS manual, has been ambulance –in old BLS manual, has been changedchanged

From different agencies = 2 PCR’sFrom different agencies = 2 PCR’s Each documents only what their service didEach documents only what their service did

PCR’s are.......PCR’s are....... Medical Records Medical Records - - Permanent part of the Permanent part of the

patients chartpatients chart

Legal Documents Legal Documents - - Proof of your Proof of your assessment and treatmentassessment and treatment

Standardized Records Standardized Records - - Statistical Statistical collection of Statewide informationcollection of Statewide information

ConfidentialityConfidentiality

The form and information contained The form and information contained on the form is confidentialon the form is confidential

EMS providers have a legal obligation EMS providers have a legal obligation to protect the confidentiality of to protect the confidentiality of patientspatients

EMS Providers must comply with new EMS Providers must comply with new federal HIPAA requirementsfederal HIPAA requirements

HIPAAHIPAA

Promulgated in 1996, Compliance Promulgated in 1996, Compliance effective April 14, 2003.effective April 14, 2003.

Covered entities includeCovered entities include– All providers of health care servicesAll providers of health care services– billing clearinghousesbilling clearinghouses– insurance plansinsurance plans

Effects ourEffects our– PCR retention schedulePCR retention schedule– use of PHI as part of the QI processuse of PHI as part of the QI process– release of PHI that you collect release of PHI that you collect

The PCR should be a The PCR should be a reflection of...reflection of...

Assessment of Assessment of patient and patient and scenescene

Care rendered Care rendered by crewby crew

And should include...And should include...

Pertinent +/- findingsPertinent +/- findings

InterventionsInterventions

Changes in statusChanges in status

Response to those Response to those changeschanges

And should include...And should include... OPQRSTOPQRST

SAMPLESAMPLE

All Vital SignsAll Vital Signs

Head-to-toe exam, vectored when Head-to-toe exam, vectored when appropriateappropriate

SOAPSOAP

SubjectiveSubjective: what the : what the patient tells you, history patient tells you, history of the present illnessof the present illness

ObjectiveObjective: P/E, +/- : P/E, +/- findingsfindings

AssessmentAssessment: : prehospital impression prehospital impression and differentialsand differentials

PlanPlan of treatment: what of treatment: what you did and the you did and the patient’s response to patient’s response to the treatmentthe treatment

What To WriteWhat To Write

Chief Complaint Chief Complaint - in the patients own words- in the patients own wordsSubjective Assessment Subjective Assessment - history of present - history of present

illnessillness events leading up to..., secondary complaints, MOI events leading up to..., secondary complaints, MOI

Presenting Problem Presenting Problem - simple check-box format- simple check-box formatPMH/Meds/Allergy PMH/Meds/Allergy - document all pertinent - document all pertinent

historyhistory be aware of heart/lung disease, diabetes, seizurebe aware of heart/lung disease, diabetes, seizure

What To WriteWhat To Write

Objective Physical Exam Objective Physical Exam - - Systematic approach, cover all body Systematic approach, cover all body areas and don’t forget pertinent areas and don’t forget pertinent negativesnegatives

How you found the patient, what How you found the patient, what problems you found, what you did to fix problems you found, what you did to fix the problem, and the response to your the problem, and the response to your

efforts to fix the problemefforts to fix the problem

What To WriteWhat To Write

Treatment Given - Treatment Given - simple check-box formatsimple check-box format Continuation Form for ALS suggested but not required Continuation Form for ALS suggested but not required

(with the exception of controlled substances)(with the exception of controlled substances)

DispositionDisposition - Don’t forget the code - Don’t forget the code

CrewCrew - Names and State EMT numbers only! - Names and State EMT numbers only! Badge/member numbers are Badge/member numbers are

UNACCEPTABLE!UNACCEPTABLE!

Why The Need For A Why The Need For A Comprehensive PCR?Comprehensive PCR?

Enhance patient careEnhance patient care

Enhance your position as a health care Enhance your position as a health care professionalprofessional

Ensure that your EMS agency has Ensure that your EMS agency has satisfactory legal evidence documenting satisfactory legal evidence documenting the responsethe response

Limit Your LiabilityLimit Your Liability September 2002- EMS crew in New Jersey September 2002- EMS crew in New Jersey

transported a patient to local ED after suffering a transported a patient to local ED after suffering a blow to his headblow to his head

Hospital discharged patient after concluding that Hospital discharged patient after concluding that injury was not seriousinjury was not serious

Patient developed seizures, became comatose Patient developed seizures, became comatose and was declared brain dead 4 days later and diedand was declared brain dead 4 days later and died

ER Physician stated he “would have ordered CT ER Physician stated he “would have ordered CT scan if [he] knew patient had vomited”scan if [he] knew patient had vomited”

EMTs were found to be negligent and liable for EMTs were found to be negligent and liable for wrongful death for FAILING to document wrongful death for FAILING to document prehospital episodes of vomitingprehospital episodes of vomiting

Writing StylesWriting Styles

DivergentDivergent– Takes into account all aspects of a complex Takes into account all aspects of a complex

situationsituationPatient fell down a 30 foot embankment with Patient fell down a 30 foot embankment with

multiple injuriesmultiple injuries

ConvergentConvergent– Focus on the most important aspects of the Focus on the most important aspects of the

situationsituationPatient is apneic with a pulsePatient is apneic with a pulse

What about ALS calls?What about ALS calls?

Pre-Hospital Care Report Continuation Pre-Hospital Care Report Continuation FormForm– Anytime a medication is administered, Anytime a medication is administered,

the Continuation Form should be usedthe Continuation Form should be used– Controlled Substances Controlled Substances requirerequire the use of the use of

the Continuation Formthe Continuation Form

What about Albuterol What about Albuterol and Epinephrine?and Epinephrine?

EMTs may administer nebulized EMTs may administer nebulized Albuterol and Epinephrine via auto-Albuterol and Epinephrine via auto-ejector; the administration of these ejector; the administration of these drugs drugs must be documentedmust be documented on on the PCRthe PCR

Patient-assisted medications Patient-assisted medications ((i.e.i.e. nitroglycerin and/or bronchodilators)nitroglycerin and/or bronchodilators) must be documentedmust be documented on the PCR on the PCR

NY State Trauma PCRNY State Trauma PCR

For all patients For all patients who’s presenting who’s presenting complaint is complaint is traumatic in nature, traumatic in nature, regardless of regardless of severity or cause, severity or cause, and regardless of and regardless of whether or not the whether or not the patient is patient is transported to a transported to a trauma center.trauma center.

(some still around…data (some still around…data points captured in points captured in RescueNet TabletRescueNet TabletPCRPCR))

Yep…I’m braggin’ Yep…I’m braggin’ here !here !

Good documentation Good documentation maymay protect everyone protect everyone

Poor documentation Poor documentation protects protects no oneno one

Which would you Which would you rather have on the rather have on the stand with you? stand with you?

What About Mistakes?What About Mistakes?

Change on all Change on all copies - strike with copies - strike with line and initialline and initial

OROR Re-write and Re-write and

destroy white and destroy white and pink copies; retain pink copies; retain yellow copy, void yellow copy, void it and submit to it and submit to Medical ControlMedical Control

Who should have Who should have access to completed access to completed

PCRs?PCRs? Agency officersAgency officers QA CommitteeQA Committee Training Coordinators Training Coordinators System/Service Medical DirectorSystem/Service Medical Director NY State EMS RepresentativeNY State EMS Representative Other Agencies that participated on the callOther Agencies that participated on the call Patients / Legal Guardians of Patients Patients / Legal Guardians of Patients

Medical RecordMedical Record

As a Medical Record, PCRs should only be As a Medical Record, PCRs should only be released when presented with a:released when presented with a:– SubpoenaSubpoena– Medical release form signed by the patient, Medical release form signed by the patient,

guardian, or estate (for legal purposes)guardian, or estate (for legal purposes)– When requested by a patient or legal guardian When requested by a patient or legal guardian

(routine purposes)(routine purposes)– EMS Division QI follow-up requestEMS Division QI follow-up request

Legal RecordLegal Record

As a Legal record, all PCRs should As a Legal record, all PCRs should be completed before :be completed before :

* Copies are separated* Copies are separated

* Leaving the receiving * Leaving the receiving hospitalhospital

Lets Clear Up the RMA Lets Clear Up the RMA Issue Issue In the event that an ambulance is dispatched to call where In the event that an ambulance is dispatched to call where

both individuals at the scene and EMS personnel believe that both individuals at the scene and EMS personnel believe that no injuries exist and that there are no individuals requiring or no injuries exist and that there are no individuals requiring or requesting EMS assistance, the appropriate PCR code 008 requesting EMS assistance, the appropriate PCR code 008 (gone on arrival) or 009 (unfounded) shall be used. An RMA (gone on arrival) or 009 (unfounded) shall be used. An RMA signature is not required, but may be obtained if desired. A signature is not required, but may be obtained if desired. A PCR, however must be completed. A physical assessment PCR, however must be completed. A physical assessment may be necessary to make a “no patient” decision. Also, may be necessary to make a “no patient” decision. Also, remember to consider High-Risk Criteria before making a “no remember to consider High-Risk Criteria before making a “no patient” found decision.patient” found decision.

If in the judgment of EMS personnel there is a patient at the If in the judgment of EMS personnel there is a patient at the scene who requires treatment and/or ambulance transport, scene who requires treatment and/or ambulance transport, but refuses, Medical Control must be contacted in an attempt but refuses, Medical Control must be contacted in an attempt to convince the patient to permit appropriate care.to convince the patient to permit appropriate care.

Lets Clear Up the RMA Lets Clear Up the RMA IssueIssue

In the event that a patient receives treatment, but refuses In the event that a patient receives treatment, but refuses transport by ambulance, and the EMS provider agrees that transport by ambulance, and the EMS provider agrees that ambulance transportation is not warranted, then medical ambulance transportation is not warranted, then medical control need not be contacted. This becomes a “treat and control need not be contacted. This becomes a “treat and release”, or a “refuses further medical assistance.” This release”, or a “refuses further medical assistance.” This decision and any recommended follow-up should be noted on decision and any recommended follow-up should be noted on the PCR and an RMA signature obtained.the PCR and an RMA signature obtained.

In the event that the EMS provider believes that ambulance In the event that the EMS provider believes that ambulance transport is indicated, Medical Control must be contacted.transport is indicated, Medical Control must be contacted.

Review of High-Risk Review of High-Risk CriteriaCriteria

Altered Mental Status or suspected head Altered Mental Status or suspected head injuryinjury

Glasgow Coma Scale less than 15Glasgow Coma Scale less than 15 Less than 18 or older than 70Less than 18 or older than 70 Neurological, cardiac, or respiratory signs and Neurological, cardiac, or respiratory signs and

symptomssymptoms Abnormal vital signsAbnormal vital signs Alcohol or drug useAlcohol or drug use CO exposureCO exposure NO RADIO CONTACT FOR RMAs NO RADIO CONTACT FOR RMAs

Bottom LineBottom Line

Very few situations turn out to be Very few situations turn out to be “unfounded”“unfounded”– If all parties neither require nor requested EMS If all parties neither require nor requested EMS

and there is no mechanism of injuryand there is no mechanism of injury– Inadvertent personal / home medical alert alarmsInadvertent personal / home medical alert alarms

There are no protocols or procedures in NY There are no protocols or procedures in NY State that allow for EMS provider-initiated State that allow for EMS provider-initiated refusalsrefusals– Your duty to act begins when you accept the 911 Your duty to act begins when you accept the 911

callcall

Common WeaknessesCommon Weaknesses

No record of patient status after treatment No record of patient status after treatment givengiven

Focused assessment does not match Focused assessment does not match presenting problempresenting problem

No Documentation for reasons something No Documentation for reasons something can’t be donecan’t be done

Common WeaknessesCommon Weaknesses Pertinent negatives omittedPertinent negatives omitted

Incomplete physical examinationsIncomplete physical examinations

Lack of Repeat Vital Signs, when indicatedLack of Repeat Vital Signs, when indicated

Use of non-standard medical abbreviationsUse of non-standard medical abbreviations

Some Beauties…Some Beauties… Spontaneous Idiopathic Fernoquadriplegia Spontaneous Idiopathic Fernoquadriplegia oror

Spontaneous Idiopathic StrykerquadriplegiaSpontaneous Idiopathic Strykerquadriplegia: : The condition in which the patient suddenly The condition in which the patient suddenly develops total body paralysis while develops total body paralysis while transferring them from your Ferno or Stryker transferring them from your Ferno or Stryker stretcher onto the hospital bed (usually affects stretcher onto the hospital bed (usually affects patients over 350 lbs).patients over 350 lbs).

Economically Challenged Urban OutdoorsmanEconomically Challenged Urban Outdoorsman – politically correct term for a homeless – politically correct term for a homeless personperson

Gravity StormsGravity Storms – causes of a rash of falls and – causes of a rash of falls and fall-related injuriesfall-related injuries

More Beauties…More Beauties… Anti-Gravity Storms Anti-Gravity Storms - The cause of - The cause of

accidents with ejectionsaccidents with ejections NKDANKDA – Not Known, Didn’t Ask – Not Known, Didn’t Ask Vitals WNLVitals WNL – We Never Looked – We Never Looked TMBTMB – Too Many Birthdays – Too Many Birthdays ART –ART – Assuming Room Temperature Assuming Room Temperature CTD –CTD – Circling the Drain Circling the Drain Just Kidding!!!Just Kidding!!!

Common OmissionsCommon Omissions

DateDate Agency CodeAgency Code Type of AlarmType of Alarm Response TimesResponse Times Presenting ProblemPresenting Problem EMT NumberEMT Number Location Code (Geocode)Location Code (Geocode) SSN - Last 4 digits only vs SSN - Last 4 digits only vs

0000 or all 9 digits0000 or all 9 digits

Rejected PCRSRejected PCRS

Will be returned to Will be returned to you for completionyou for completion

May inhibit your May inhibit your QA/QI effortsQA/QI efforts

Increases liabilityIncreases liability Agency does not Agency does not

receive credit for receive credit for number of responsesnumber of responses

Reduced future Reduced future delivery of PCRsdelivery of PCRs

Karl’s Pet PeevesKarl’s Pet Peeves

““Sluggish Pupils” Sluggish Pupils” (is that before or after algebra?)(is that before or after algebra?)

Measuring the depth of lacerations Measuring the depth of lacerations (hopefully that (hopefully that

ruler is BBP compliant!)ruler is BBP compliant!) Using the dispatch data as the chief complaint Using the dispatch data as the chief complaint

(I didn’t think the person said “I’m having an MVA”)(I didn’t think the person said “I’m having an MVA”) The term “neuro deficit” The term “neuro deficit” (were you able to measure (were you able to measure

that?) that?) The A&O x 3 scale The A&O x 3 scale (wasn’t that a Railroad in Monopoly?)(wasn’t that a Railroad in Monopoly?) If you use a medical word - know what it If you use a medical word - know what it

means and how to spell it means and how to spell it (hey- Anna Falaxis, is that (hey- Anna Falaxis, is that you?)you?)

Yes, I actually saw Yes, I actually saw these...these... John Dow John Dow

Posed Dictal Posed Dictal Sinkable Sinkable Groinal AreaGroinal Area Consous Consous Reveils Reveils Difrederick Difrederick AntiobiodackAntiobiodack Glue CoastGlue Coast

Please Please help help me...me...

Helpful HintsHelpful Hints

Your PCR should be like a math Your PCR should be like a math problem…..problem…..

Subjective InterviewSubjective Interview

++ Objective ExaminationObjective Examination

=Treatment Plan=Treatment Plan

PrehospitaPrehospital l ImpressioImpressionnInterventionIntervention

ssResponseResponse

Helpful HintsHelpful Hints

If you want to do it, and the patient doesn’t If you want to do it, and the patient doesn’t let you - tell them why they need it, and let you - tell them why they need it, and what may happen if you don’t do it - and what may happen if you don’t do it - and DOCUMENT IT AND GET A SIGNATUREDOCUMENT IT AND GET A SIGNATURE

If the protocol calls for it and the patient If the protocol calls for it and the patient doesn’t want it - tell them why they need it, doesn’t want it - tell them why they need it, and what may happen if you don’t do it - and what may happen if you don’t do it - and DOCUMENT IT AND GET A SIGNATUREand DOCUMENT IT AND GET A SIGNATURE

Helpful HintsHelpful Hints

If the protocol says you need to do If the protocol says you need to do it - and you can’t do it - it - and you can’t do it - DOCUMENT IT on the PCR.DOCUMENT IT on the PCR.

Supporting Supporting DocumentationDocumentation

Public Health Law Article 30Public Health Law Article 30

NYCRR Part 800.21NYCRR Part 800.21

NY State EMS Policy Statement 02-05NY State EMS Policy Statement 02-05

Suffolk County Operations Policy 2-Suffolk County Operations Policy 2-001 001

What about changes What about changes after the PCR is after the PCR is

submitted?submitted? Complete an Complete an

addendum for the addendum for the original recordoriginal record

NEVER alter the NEVER alter the original service original service copycopy

Provide copy of Provide copy of changes to hospital changes to hospital and State for their and State for their recordsrecords

Let’s Look at a Few Let’s Look at a Few PCRs…PCRs…

((The Good, The Bad, and The Ugly)The Good, The Bad, and The Ugly)

The Good…The Good…

The Ugly…The Ugly…

OK…What’s this HIPAA OK…What’s this HIPAA stuff everyone’s talking stuff everyone’s talking

about?about?

HIPAA and PCRsHIPAA and PCRs

Health Insurance Portability & Health Insurance Portability & Accountability ActAccountability Act– Enacted in 1996Enacted in 1996– Full compliance by Full compliance by all health careall health care

entities entities (can you say EMS?)(can you say EMS?) REQUIREDREQUIRED by April 14, 2003 by April 14, 2003

HIPAA and PCRsHIPAA and PCRs

Regulations affect ambulance and Regulations affect ambulance and first response services in three first response services in three specific areas:specific areas:– PCR Retention SchedulePCR Retention Schedule– Utilization of protected health Utilization of protected health

information as part of your agency’s information as part of your agency’s QA/QI programQA/QI program

– Release of protected information your Release of protected information your agency collects on a PCR to a patientagency collects on a PCR to a patient

PCR Retention PCR Retention ScheduleSchedule

NYS-DOH Policy NYS-DOH Policy Statement 02-05Statement 02-05– Keep white copy 6 Keep white copy 6

years, or 3 years years, or 3 years past a patient’s past a patient’s 1818thth birthday, birthday, whichever is whichever is longerlonger

SCEMS Policy SCEMS Policy Statement 1-010 Statement 1-010 and 2-001and 2-001

How Long Do We Keep How Long Do We Keep Them?Them?

Must be kept in a Must be kept in a secure locationsecure location

6 years (HIPAA)6 years (HIPAA) 3 years from the 3 years from the

child’s 18th. child’s 18th. Birthday, or 6 years, Birthday, or 6 years, whichever is longer whichever is longer

5 years if Controlled 5 years if Controlled Substances were Substances were usedused

PCRs and QAPCRs and QA

EMS agencies are encouraged to EMS agencies are encouraged to use PCRs as part of their QA/QI use PCRs as part of their QA/QI effortsefforts

ALL personal indicators on the PCR ALL personal indicators on the PCR must be eliminatedmust be eliminated

““Blacked out” name, address, date Blacked out” name, address, date of birth and call location remains of birth and call location remains acceptable when distributing acceptable when distributing copies to QA Committee for reviewcopies to QA Committee for review

Release of InformationRelease of Information

Faxed copies OK; Faxed copies OK; must ensure must ensure recipient receivedrecipient received

Release form Release form signed by patient signed by patient or by attorney on or by attorney on behalf of patientbehalf of patient– In person with IDIn person with ID– Keep record of all Keep record of all

releasesreleases

PCRs may be PCRs may be released to:released to:– NYS-DOH NYS-DOH

employee as part employee as part of inspectionof inspection

– EMS Medical EMS Medical Director or Director or designee designee

– Countywide QI Countywide QI processprocess

– In response to In response to Notice of ClaimNotice of Claim

Where Can I Get Help?Where Can I Get Help?

New York State DOH-New York State DOH-Bureau of EMSBureau of EMS– EMS Agency EMS Agency

Operational Resource Operational Resource GuideGuide

Section 8 – Instruction Section 8 – Instruction Manual for Prehospital Manual for Prehospital Care ReportCare Report

Suffolk County EMS Suffolk County EMS Operations ManualOperations Manual

Any Questions ?Any Questions ?