Rapid City Fire Department Pre-Hospital Advanced Life Support Protocols

Section 6 Operational Protocols

Protocol 6.11: Patient Care Report (PCR) Requirements

General principles:

A. The Patient Care Report (PCR) is an integral component of patient care, the quality improvementprocess and is a professional/legal responsibility of the EMS provider.

B. The Patient Care Report (PCR) is many times the sole source of information regarding the patient’scondition and any pre-hospital treatment they received. It is imperative that the information isaccurate, complete and provided to the receiving hospital in an expedient manner in order toprovide for an efficient and safe continuation of care.

C. The Patient Care Report (PCR) is the legal record of the EMS providers encounter with the patient,and the treatment and transport that patient received. The PCR is discoverable in a court of law andcan be (and frequently is) subpoenaed. Given that fact, the PCR must be complete and it must beaccurate in all respects.

D. The Patient Care Report (PCR) is also the primary tool used by patient billing services to collect feesfor ambulance services, which is the primary funding source for the EMS system. The PCR must becomplete and it must be accurate to allow the billing process to take place in an expedient mannerand to satisfy federal regulations regarding ambulance billing.

Procedures:

A. The procedures detailed herein apply to any electronic charting method the Department is currentlyusing.

B. All documentation of patient care will be written in the L-CHART format. The following is the

minimum guide as to what should be included in your narrative:

“L” Location Unit identifier and location/address or type of location dispatched to.

o Example: Urgent Care, Patient Residence, etc. Type of response per dispatch

o Emergent with lights and sirens or non-emergent without lights and sirens. Assurethis matches dispatch priority and use of lights/sirens on response tab.

Exact reason you were dispatchedo Nature of call

Arrive on scene informationo Scene size up- detailed description of what you see

Location and condition of pt.o Is patient in distress? Sick or not sick?o Include documentation on who else is on scene and if they have effected the scene

in any way (i.e. initiated CPR, moved the patient, etc.).

“C” Chief Complaint

A brief statement of the patient’s primary problemo Usually comes from the patient, use quotes if possibleo What is the reason for calling an ambulance

Unconscious/unresponsive or cardiac arrest can be a C/C

Rapid City Fire Department Pre-Hospital Advanced Life Support Protocols

Section 6 Operational Protocols

“H” History

SAMPLE History OPQRST MOI [trauma] or NOI [medical] Past Medical History Associated complaints / symptoms / DNR Orders What was Pt treated for/diagnosed with if being transferred Any additional details about the call not addressed above

“A” Assessment

Primary Assessment-

Systemic Physical Exam ABC's / LOC / GCS / AVPU and list any and all immediate life threatening injury or

condition. Airway

o Patent?o Trauma or medical condition affecting the airway?o Obstruction?o Patient vomiting

Breathingo Spontaneouso Rate and quality of breathingo Breath soundso Chest rise fall equalo Difficulty breathing- use of accessory muscles, nasal flaring, or Pt position (tri-pod)

Circulationo Pulses presento Rate and quality of pulseo Skin condition and coloro Skin temperatureo Bleeding present, type of bleeding, and how much has patient lost

Alert and Oriented to (A&Ox3/3or x4/4)o Quantify your findings (i.e. A&Ox3/4 Pt not alert to time)

Complete set of vital signs within the first few minutes of contacting patient to include a glucose level check.

Secondary Assessment-

Detailed head to toe examination to include a secondary set of vital signs.o HEENTo Necko Chesto Abdomeno Pelviso Backo Extremities

Rapid City Fire Department Pre-Hospital Advanced Life Support Protocols

Section 6 Operational Protocols

Documentation should include:

Pertinent negatives

Rule out criteria

Temperature

Glucose level

Minimum 2 full sets of vital signs

Cardiac monitor interpretation of rhythm and conditions effecting output

Stroke assessmento Document details on BEFAST assessmento Documentation will include pertinent negatives and rule out criteria

PBT values - Acquire if ETOH suspected to have cause. You may need to ask lawenforcement for one to be administered.

Any injury or condition that supports the C/C will be completely assessed.

“Rx” Treatment

Treatment documentation should include these four items:o Clinical indications for treatment- the whyo Description of the treatments- the whato Identity of who performed the treatment- the whoo Reassessment and results of treatments- how did it go

Documentation of treatment/interventions will be in both the Procedures/Medications taband the narrative.

Medications and interventions will have vital signs before and after administration

Document any changes in condition

*Any Level 2 or Physician based treatments will be documented to include name of Physician andoutcome*Any protocol deviation will be documented

“T” Transport

Document what mode you transported paitent in (emergent with lights and sirens or non-emergent without lights and sirens.

Document patient position during transport.

Document securing of patient to cot.o Not just cot straps, but how many

Any events with pt care during transport

Patient personal property- what it is and where you put it

Where you transported to, name of receiving staff, and room number

Transfer of patient to cot

“Pt was moved to cot” is not acceptable

Explain how it happened

Rapid City Fire Department Pre-Hospital Advanced Life Support Protocols

Section 6 Operational Protocols

3 basic types of patient transfers-

Total assistance

Pt is team lifted

Document any adjuncts neededo LBBo KEDo Mega Movero Stair Chair

Partial assistance

Pt able to stand and pivot with assistance

Pt able to walk short distance with assistance

Pt can assist with moving by sliding across bed

Assistance by us or other staff, family members

For any assistance required document why assistance was needed

Pt bed confined, non-weight bearing, unconscious/unresponsive, etc. Injury, weakness, etc. Acute illness

Stroke HX

ALOC, difficulty following commands

No assistance

Pt able to stand and walk on own

Able to get to cot and sit by self

Signatures: All appropriate signatures will be obtained from the patient (or representative), both crew members (and any additional crew members involved in patient care), and the receiving facility in accordance with our current signature policy.

All reports shall be finalized, posted, and printed at your station upon completion of the call.

Additional Considerations: In all circumstances, Patient Care Reports shall be completed in sufficient detail to allow the receiving medical facility , EMS Section Chief, system Medical Director, and billing department, to easily determine the nature and extent of the patient’s injury or illness and any treatment rendered.