PCR In-service For NYS Version 5 PCRs

What is a Patient Care Report? Patient Care Reports (PCRs) are legal documents which are used to record pertinent health information about pre-hospital patients.

What is a PCR? A PCR is a three part document printed on non-carbon copy paper, attached at the top. Three parts are usually referred to as ‘white’, ‘yellow’ and ‘pink’ The ‘White’ copy is retained by your EMS agency for 6 years, or 3 years past the patient’s 18th birthday; whichever is first. The ‘Pink’ copy is turned over to transporting agency, or to the hospital. ‘Yellow’ copies are sent monthly to the Office of Prehospital Care, and later to the State Department of Health for research.

Why do we have to use PCRs? Ambulance Services and ILS/ALS level agencies are required by public health law to use the New York State PCR NYS Public Health Law, Article 30: “…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”

Why are PCRs important? PCRs are legal documents PCRs protect responders by serving as a legal record of patient interaction Can be subpoenaed in legal proceedings PCRs help patient care Provide a record of care provided for a patient, so that treatments are not duplicated, and can be expanded upon during the full course of patient treatment PCRs are used for research PCRs are used in statistical research to identify strengths and weaknesses in the EMS system, with the goal of improving patient care across New York State.

When should I use a PCR? PCRs should be completed each time your agency is dispatched for ANY response when EMS may be needed: All patient transports All patient refusals Any time there is contact with a patient Certain calls when no patient contact is made: Call cancelled before reaching the scene Call when no patient is located Stand-by events There must be one PCR specifically for the stand-by and additional PCRs for any treated patients.

Multi Agency Response When more than one agency responds to a scene, each service should complete a separate PCR. Each PCR should reflect only the actions taken by that crew.

Before we start…. Call Received as Use black ink for PCRs Fill in the circles completely, do not place ‘X’ or check marks in the boxes A circle Should be filled in like this Not this Call Received as EMERGENCY NON EMERGENCY STANDBY X

Before we start…. Use Military time (24 hour clock) Be careful not to write on top of other PCRs, the writing will be transferred through the copy paper to unintended copies. Write legibly!

You pull up on scene, and see: You are responding with the fire department, and your Chief assigns you and your crew to take care of the driver of the green SUV, who is outside of his vehicle, walking around. This training is based on your assessment of this patient and documentation as a First Responder.

Date of call Run number Agency Code Vehicle ID 0 3 3 1 0 8 0 0 2 5 4 1 Enter date that the call is initially dispatched on Run number Enter the number that is assigned by your dispatcher or agency. Depending on your system, you may not receive this until after the call. Agency Code Enter the number that is assigned to your agency by New York State Department of Health Bureau of EMS Vehicle ID Enter the identification number of the vehicle that responds to the call 0 3 3 1 0 8 0 0 2 5 4 1 0 0 1 4 9 0 0 0 0 3 2 2

Agency Name Dispatch Information Call Location AGENCY NAME XYZ EMS Agency Minor injury Motor Vehicle Accident Harlem Rd and Cleveland Rd Agency Name Insert the name of your EMS Agency Dispatch Information Insert the nature of the call as it was dispatched Call Location Insert the location of the call by address, intersection, or highway mile marker

Location Code Location Type 1 4 5 5 Enter the four digit municipality code for the municipality in which the call takes place. Location Type Residence: Private homes, multiple occupancies (ex. Apartments, dormitories, etc) Health: A place where medical care is routinely provided Farm: A rural place where agricultural products or livestock are raised Industrial A place where a product is manufactured or stored Other work A place of work other than industrial facility (ex. Offices) Recreational Places organized for recreation or sport, but excluding homes and industrial places Roadway A place that is designated as a thoroughfare for motor vehicles. Not a private residence driveway Other Any other place that does not fit into any of the above categories 1 4 5 5 Industrial Other Work Recreational

Call Received as Fill the circle of how the call was received from the dispatcher EMERGENCY: Call dispatched as an emergency, or potential emergency. This box should include any emergency or critical care transfers NON EMERGENCY: Routine calls such as non urgent, or scheduled transports or transfers STANDBY: Unit dispatched but no patient is treated such as when covering a special event, standing by at a fire or covering another station for mutual aid.

Patient Information J o h n S m i t h 1 2 3 M a i n S t 7 1 6 1 2 3 4 5 6 7 A k r o n NY 1 4 0 0 1 4 0 0 1 2 2 1 9 6 8 1 2 3 4 5 6 7 8 9 Name: Enter patient name, if unknown write either “John Doe” or “Jane Doe”. If no patient, write “No patient” Address: Write patient address, if unknown, write ‘unknown’ Age: Enter age of patient. Age must be entered, regardless if DOB is present. If age is unknown, enter approximate age. If the patient is less than one year of age, enter either ‘H’ for hours, ‘D’ for days, or ‘M’ for months. (ex. 7 months entered as ‘7M’) Date of Birth Enter the patient’s date of birth, if unknown, enter zeroes. Social Security Number Enter the patient’s Social Security Number, if unknown, write ‘000-00-0000’

Physician: Enter name of patients primary doctor, if possible Dr. Strangelove

Care in Progress on Arrival Indicate the type of care, if any, the patient received prior to your arrival. Indicate what was done for the patient during this time in the comment section. None: The patient is not receiving any care Citizen: Care is being administered by an individual without any level of EMS certification PD/FD/Other First Responder: Care is being administered by a member of a Police or Fire Department or another certified First Responder Other EMS: Patient is being cared for by a Physician, Nurse, EMT or Paramedic (may be off duty) PAD used: The patient was defibrillated using a Public Access Defibrillator

Mechanism of Injury Fill the appropriate circle as to how the injury occurred If the call is of a medical nature, fill in the last circle and write ‘Medical’ in the space provided

Extrication required: Fill the circle if the patient needed to be extricated This applies to any situation when extraordinary measures needed to be taken to prepare a patient for treatment/transport Fill in the blank with the approximate duration of extrication efforts, from on scene time, until the patient is free from entanglement Seat belt used: Fill the appropriate circles for any patient involved in a motor vehicle accident, and indicate who gave this information

Chief Complaint “My neck hurts” Record the patient’s chief complaint in their own words Ex. “I’m having chest pain” If the patient is unable to unwilling to offer a chief complaint, state that the patient is unable to offer a chief complaint at this time.

Subjective Assessment: What the patient, family or bystander says Pt states he was driving when he was struck from behind, sending his car up into the air. Pt states he did not lose consciousness, but had a sharp 7/10 pain in his neck. He denies airbag deployment. He states was able to open the door and get himself out of the car prior to our arrival. Patient denies chest pain, SOB, or back pain. An elaboration of the patient’s Chief Complaint, based on the history obtained by the provider from the patient. If the patient cannot speak, then obtain from family or bystanders, and indicate the source of information

Presenting Problem Neck Fill in the appropriate circle to indicate the patient’s presenting problem. If there is more than one, fill in all the appropriate circle, and place a large circle around the primary problem

Past Medical History List patient allergies. If none, write ‘No Known Allergy’, or ‘NKA’ in the space provided Fill in all appropriate circles, and list additional medical problems List medications in the space provided If more space is needed, continue to the comments section or continuation form NKA Metoprolol 50mg b.i.d., Albuterol prn

Vital Signs Vital Signs 0 7 2 5 138 15 92 0 7 3 6 134 15 86 20 104 20 104 0 7 2 5 138 15 92 18 90 0 7 3 6 134 15 86 Vital Signs Enter each set of vital signs in the space provided, if more than three sets are obtained, use the comment section or a continuation form. Always attempt to get two sets of vitals in order to establish if a trend is present (ex. decreasing blood pressure) Be sure that a time is entered

Objective Assessment: What you observe PE: ♂ in apparent distress, holding his neck. Pt CAOx3, no JVD or tracheal deviation present, no deformities to neck, equal chest expansion bilat, with clear lung sounds, ABD-SNTx4, pelvis-stable, good PMSx4, strong equal grips bilat., patient presents without neurological deficit, no other injuries or complaints found throughout. Pt ambulatory PTA  primary eval  manual c-spine held  secondary eval  c-collar applied  vitals  standing takedownbackboardstretchervitalspt turned over to Rural/Metro 555 for transport to St Joes. CF Objective Physical Assessment Enter in this section a summary of the primary and secondary assessment of the patient. This should be a complete head to toe assessment You don’t have to repeat the same information that you filled out a circle for above, unless it changes Comments Use this section for information which is pertinent, but does not fit in any other section Includes: medication list, additional sets of vital signs, continued physical assessment, etc. At the end of your narrative, insert initials to signify that the statement is complete.

Treatment given In this section, mark all treatments given by your agency. If treatments were performed prior to your arrival, indicate this in the comments section Do not mark treatments performed by another agency

Disposition Disposition Code Turned over to RMA 555 for transport to St Joes 0 0 4 Disposition If your unit transported the patient to the hospital, nursing home, or other medical facility, enter name of such facility. If your unit transported the patient to the hospital, also include the reason for transport (ex: ‘closest facility’, ‘patient choice’, ‘trauma center’) When these do not apply, enter the phrase from the ‘Disposition Code’ list found on the back of the PCR that best describes the call outcome. Disposition Code Enter the code number for the hospital transported to, or from the back of the PCR.

Crew Members Enter the names of the crew members. S. Wander C. Fenar E. Bordonaro A. Major 1 1 0 3 4 6 3 1 0 8 1 8 2 2 5 6 4 9 0 0 0 0 0 0 Enter the names of the crew members. The crew member in charge of the patient must be entered in the first box; the driver’s name should be entered in the second box. When the crew member is certified at any level, fill in the circle corresponding to their current certification level, and enter their six digit NYS certification number. If the person is not NYS certified, enter the individual’s name, and fill the boxes with zeroes

Required Elements When cancelled prior to arrival on scene Date of call, Agency Code, Vehicle ID, Dispatch information, Agency Name, Call Location, Location Code, Social Security Number (filled in with 000-00-0000) Dispatch information, Type of call (Emergency/Non-Emergency/Stand-by), Time call received, Time service responded, Disposition and disposition code, Crew names, level of certification and number.

Required Elements When ANY patient contact occurs Date of call, Agency Code, Vehicle ID, Dispatch information, Agency Name, Call Location, Location Code, Type of call (Emergency/Non-Emergency/Stand-by), Time call received, Time service responded, Disposition and disposition code, Patient Name, Patient Date of Birth, Patient Gender, Social Security Number Presenting problem, Vital signs if a patient was indicated on the form, Chief Complaint, Subjective Assessment, Objective Physical Assessment, Past Medical History, All treatment provided by your agency Crew names, level of certification and NYS certification number

When patient refuses transport Required Elements When patient refuses transport Same as when any patient contact occurs, PLUS a WREMAC approved refusal form MUST be utilized

Remember… Write only what your agency did Zeroes in any boxes that are left blank or if the answer is unknown Horizontal lines across any section left blank Use only approved abbreviations

Remember… Subjective is what the patient Says Objective is what you Observe Mistakes should have one line through it, and it should be initialed. Initial at the end of your narrative statement – do not draw lines or scribble across the remaining space

Questions/Comments? Department of Health PCR Policy Statement Feel free to contact the Office of Prehospital Care at (716) 898-3600 or... Bill Major, Program Coordinator wmajor@ecmc.edu Beth Bordonaro, PCR Specialist ebordona@ecmc.edu Thanks to Cleveland Hill Fire Department for the MVC pictures