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The prehospital care report (PCR) contains
- Administrative information
- Unit identification.
- Crew members and levels of certification.
- Address of dispatch.
- Time of incident report, dispatch, arrival on-scene, departure, arrival at medical facility and transfer of care.
- Patient data
- Name, age, sex, birth date.
- Home address.
- SSN and insurance / billing information.
- Location of the patient.
- Any care given before arrival of the EMTs.
- Vital signs
- Breathing.
- Pulse.
- Skin.
- Pupils.
- Blood pressure.
- Puls-ox.
- Patient narrative
- Chief complaint.
- MOI/NOI.
- SAMPLE history.
- Physical exam / assessment findings.
- Pertinent negatives (absence of expected signs/symptoms).
- Treatment
- What was provided.
- When it was provided.
- Patient's reaction to it.
If patient refuses treatment
- Check to make sure the patient is competent to refuse.
- Alert and orientated.
- Is not under the influence of alcohol or drugs.
- Is not suicidal.
- No altered mental status.
- Persuade patient to change his / her mind.
- Explain why he or she needs to go to the hospital.
- Discuss possible consequences if not treated.
- Consult with medical direction.
- Sign refusal-of-care form.
- Document that the patient is alert and orientated.
- Document reasons for refusal.
- If patient refuses to sign, have a witness sign and verify the refusal.
- Give patient an open alternative.
- Offer alternative methods of getting care.
- Let the patient know that EMTs will be happy to come back if he or she changes her mind.
Other
- Never erase from the PCR. Always cross out mistakes with a single line and initial it.
- During multiple-casualty incidents, usual documentation procedures are not followed so that EMTs can concentrate on treating patients. Information from triage tags can later be documented into PCRs.
- While PCR is the main documentation for EMTs, special incidences (such as child abuse, exposure to infectious diseases, and injury to a crew member) require special documentation.
- Minimum data set
- Regulation by the DOT.
- Must be included in all PCRs.
- Includes chief complaint, mental status, vital signs, and timing of events from incident report to transfer of care.
- Documentation is used for medical, administrative, legal, educational and research purposes.
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