INSTRUCTION MANUAL FOR PREHOSPITAL CARE REPORT
Revised May 2003
An essential part of any prehospital medical care is the documentation of the care provided and the medical condition and history of the patient. The Prehospital Care Report (PCR), used as a requirement of Part 800, is the instrument developed and distributed for this documentation. The primary purpose of the PCR is to document all care and pertinent patient information as well as serving as a data collection tool.
The documentation included on the PCR provides vital information, which may be necessary for continued care at the hospital. As part of transferring the patient to the Emergency Department Staff the agency should not leave the hospital until a completed PCR is provided to the appropriate hospital staff.
A PCR should be completed each time the agency is dispatched for any type response. This includes (but is not limited to):
- Patients transported to any location,
- Patients who refuse care and/or transport,
- Patients treated by one agency and transported by another,
- Calls where no patient contact is made, such as
- Calls cancelled before reaching the scene
- Calls where no patient is located
- When dispatched for a stand by
If an agency is dispatched to a stand-by and while there they treat a patient, two PCRs should becompleted.
All information on the PCR should be legible and printed in black ink.
Any member of the crew may enter information on the PCR. The individual indicated as "In Charge" should be the person who provided or directed the care to the patient. There is no requirement that the person in charge be certified as the highest level of care present. However the individual indicated as in charge is responsible for the care provided and documented. The provider listed as "In Charge" must be at least an EMT. If any advanced life support care was provided to the patient, the provider listed as "In Charge" must be an advanced EMT at the level appropriate for the care provided.
On each PCR the following information must be entered:
- Date of call,
- Agency Code,
- Vehicle ID,
- Dispatch information,
- Agency Name,
- Call Location
- "Geo" code
- Dispatch information,
- Type of call: Emergency/Non-Emergency/Stand-by,
- Time call received,
- Time service responded,
- Disposition and disposition code,
- Patient Name; If no Patient state "No Patient",
- Patient Date of Birth,
- Patient Gender,
- Presenting problem, if more than one, circle the primary 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, do not include treatment provided by other another agency,
- Crew names, level of certification and NYS certification number.
- Dispatch Codes (Southern Tier transporting agencies only).
Pink (Hospital Patient Record) Copy:
- Ambulance Service: Must leave pink copy at the hospital prior to the agency leaving the hospital. (Note: This copy is identified by a pink stripe along the bottom edge of the page.)
- Advanced Life Support First Response (ALS FR) Agency:
- Must be provided to the transport agency prior to the transport agency leaving the scene if no representative of the agency will be accompanying the patient to the hospital.
- If a representative is accompanying the patient than they must provide the completed copy to the hospital prior to leaving (as above).
- Basic Life Support First Response (BLS FR) Agency: Same as for ALS FR Agency.
Yellow (Research) Copy:
- Ambulance Service: Yellow copy shall be submitted by the service to the Regional EMS Program Agency as designated by the Department. PCRs shall be submitted at least monthly, or more often if so indicated by the program agency. (Note: this copy is identified by a yellow stripe along the bottom edge of the page.)
- Advanced Life Support First Response (ALS FR) Agency: Same as for an ambulance service.
- Basic Life Support First Response (BLS FR) Agency: BLS FR agencies are not required to use three part PCRs. They may use a two part PCR, available from their Regional EMS Program Agency. BLS FR agencies are not required to submit the research (yellow) copy. If a three part form is used, the research copy may be destroyed by the agency.
NOTE: There are agencies participating in projects submitting data directly to the Department of Health electronically. These are the only agencies exempted from this provision.
White (Agency) Copy:
- All Agencies: The original white copy should be retained in a secure location at the services permanent office as designated to the Department for the following time periods:
- Federal Law (HIPPA) requires that medical records be retained for six Years, if the call does not involve the treatment of persons under age 18. If the call does involve the treatment of persons under age 18, the PCR must be retained for three years after the child reaches age 18.
Confidentiality & Disclosure Of PCRs/Personal Healthcare Information: Maintaining confidentiality is an essential part of all medical care, including prehospital care. The confidentiality of personal health information (PHI) is covered by numerous state and federal statutes, Polices, Rules and Regulations, including the Health Insurance Portability & Accountability Act of 1996 (HIPAA) and 10 NYCRR.
10 NYCRR (Health) Part 800.21:
Every person certified at any level pursuant to these regulations shall:
(a) At all times maintain the confidentiality of information about the names, treatment, and conditions of patients treated except.
(1) A prehospital care report shall be completed for each patient treated when acting as part of an organized prehospital emergency medical service, and a copy shall be provided to the hospital receiving the patient and to the authorized agent of the department for use in the State's quality assurance program;
Health Insurance Portability & Accountability Act of 1996 (HIPAA):
Federal Law (HIPAA) requires all healthcare providers to have a written policy on protecting Personal Health Information (PHI), including PCRs.
Such a policy should include (but not be limited to):
- Indicate that requests from patients for PCR copies be in writing;
- That the agency will maintain a copy of the written request with the original PCR;
- Maintaining the confidentiality of the information contained on a PCR as well as the actual PCRs;
- Conducting security training for all employees/members in proper security procedures to protect personal health information; and
- Documenting security training of employees/members.
Providing PCR copies to the receiving hospital, other providers giving care in a tiered system and to the EMS program agency for QI does not constitute a violation of the HIPAA regulations. For additional agency specific questions regarding HIPAA agencies should contact their legal counsel and/or the U.S. Department of Health and Human Services.
Other PCR Disclosures:
The PCR may also serve as a document called upon in legal proceedings relating to a person or an incident. No EMS agency is obligated to provide a copy of the PCR simply at the request of a law enforcement or other agency. If a copy of the PCR is being requested as part of an official investigation the requestor must produce either a subpoena, from a court having competent jurisdiction, or a signed release from the patient. Except that copies of PCRs must be made available for inspection to properly identified employees of the NYS Department of Health.
A person may request a copy of a PCR completed for themselves as the patient or the parent or legal guardian of a patient may obtain a copy of a PCR completed for that patient. In cases where the patient is now deceased the person who is the court appointed legal representative of the patient's estate may request a copy of the PCR.
An agency may provide a copy of a PCR to those entities that represent that agency either for the purpose of collection of fees from the patient or their insurance carrier or as part of any legal proceedings relating to the agency. In such situations those representative are also responsible for protecting the personal health information contained within the document.
All hospitals in New York State have a three digit code indicting the hospital. In addition the name of the hospital must be indicated.
|Non Hospital Disposition Codes||Meaning||Example|
|001||Nursing Home||Any nursing home, rehabilitation center, respite home or extended care facility not listed with a hospital disposition code.|
|002||Other Medical Facility||Includes outpatient and specialty clinics, doctor's offices, diagnostic and testing facilities.|
|003||Residence||When a patient is transported to a private residence.|
|004||Treated By This Unit & Transported
By Another Unit
|In a multi tiered response system this disposition would be used by any BLS FR or ALS FR agency. This code would also be used if one ambulance service provides ALS interface for another ambulance. It would not be used by multiple vehicles from the same agency i.e. two ambulances are dispatched to the same call.|
|005||Refused Medical Aid and Or
|Any time contact is made and a person is evaluated, to include such procedures as vital signs being taken, or any treatment is provided. The documentation included on the PCR must indicate that the patient was advised of the need for care and the patient was competent to make an informed refusal of such care.|
|006||Call Cancelled||Any time a call is canceled prior to the arrival of the EMS agency this disposition code should be used. When possible the crew should document what other agency canceled the response or the reason for the cancellation.|
|007||Stand By Only
|Used if a service is dispatched for a call such as to stand by during a fire or other incident. If any person is treated at the scene an additional PCR should be completed for them.|
|008||No Patient Found||If a service arrives at a scene and there is no one there with any complaint or injury, this code should be used. This would include being dispatched to a motor vehicle crash at which there are no persons who require any evaluation or care to. Document completely under Comments|
|010||Other||Any instance not indicated or explained above. This might include a lift assistance call for a person who has fallen. Document completely under Comments|
NOTE: It is impossible to include every possible scenario an effort is made to provide guidance on many common occurrences.
The Department of Health maintains a data system that tracks all inpatient care in hospitals by linking some of the data, Version-5 of the PCR will allow for the collection of additional data. That will allow linking prehospital patient care and the care provided by the emergency department and if admitted the hospital through to discharge. The linkage is obtained by certain identifying factors such as digits of the social security number and several of the characters in the patient's last name. This will permit the EMS system to better determine the effectiveness of the care given in a prehospital setting for quality assurance purposes.
Version-5 also includes characteristics necessary to utilize this form as a scannable instrument. Optical Character Recognition (OCR) will permit the form to be scanned and have the data extracted from it into useable tables. The only way this will be accomplished is if the person completing the form prints legibly. This will allow agencies, counties or regions to consider scannable systems locally.
Completing a Version-5 PCR:
While the form looks different, all of the previous items contained in a PCR are continued on the Version-5. Several items have been added and the format that information is entered has also been changed. Added to the Version-5 are:
- Boxes for providing the patient's social security number (SS#)
- An indication if the patient was defibrillated by a Public Access Defibrillation (PAD) Provider.
- The patient's Date of Birth is now an 8-character entry requiring the century to be included. This field is located on the bottom line of the patient information box between the box for the patient's age and the circles for the patient's gender.
The other differences between Version-5 and the previous versions include:
1. Boxes are now provided for each character of agency and patient identifying information.
- Please place one character in each box.
- Do not draw lines through boxes that are not relevant to the patient.
- Print carefully and legibly.
2. The Presenting Problem, Treatment Given and several other "Boxes" are now circles.
- Please completely darken each circle that is applicable.
- The Presenting Problems and Treatment Given sections are now printed with red ink. This red ink will not be recognized when the form is scanned. This feature is essential when the scanning process is implemented.
- Do not use X or check-mark to indicate a selection.
There are no special tools required to complete the PCR, however it must be completed using black ink to be read by a scanner.
The PCR is a three-part document printed on NCR paper. Each form is bonded at the top. Care must be taken that what is written on one PCR set does not come through on the set below (an aluminum form-holder clipboard is recommended). It is important that firm pressure with a ballpoint pen be used. Be as neat, complete and accurate as possible when completing this form. If a section does not apply to a particular call, leave it blank. Do NOT write NA or draw lines across sections of the form; this can cause scanning errors. It is important for the crew members to review the document before it is submitted. If an error is made prior to the PCR being submitted, enter the correct information on a second PCR and destroy all copies of the first form.
Military time must be used for all time entries on the PCR. Military time can be easily calculated by adding 12 hours to any time after noon and before midnight. All military times are in four-digit form.
|12:00 PM (Noon)||1200|
|12:00 AM (Midnight)||2400|
RED AREAS ON THE PCR
Some areas of the PCR are printed in red. This is for scanning purposes, the scanner does not read red (please be sure you fill out the form with black or blue ink).
THE BACK OF THE FORM
Non-Hospital Disposition Codes: A listing of codes used other than state hospital codes.
Hospital Receiving Agent: This section is available for those agencies required to obtain a signature from the hospital personnel receiving the patient. When used, open the form so that the signature is on the agency (white) copy only (if you do not open the form, the signature will not appear on your agency copy).
Refusal of Treatment/Transportation Release: This section is provided for legal protection when a patient refuses treatment or transportation by your agency. When used, open the form* so that all entries are on the agency (white) copy only (if you do not open the form, the signature will not appear on your agency copy). Circle "treatment" and/or "transport to a hospital" and have the patient and the witness sign on the lines provided.
The Rule of Nines: Figures are for your reference in assessing burn severity.
Glasgow Coma Scale and Trauma Score: Guides are for your reference in completing the Vital Signs section of the PCR.
ICD Diagnostic Code: for Hospital use only.
Insurance Data: Enter the insurance information that your agency requires.
*Any time you write on the back of one of the pages, you must open the form so that what is written does not destroy the data on the front of the page.