The Patient Care Report (PCR), also called a Prehospital Care Report, is the legal document used by first responders to record all aspects of the care a patient receives from initial dispatch to handoff in the hospital.
All U.S. states require at a minimum documentation of:
- The patient's initial condition,
- The care provided by first responders and EMS providers,
- The status of the patient during the ambulance transport, and
- Responses to any treatments.
A detailed, well executed Patient Care Report can help the hospital care team guide treatment later in the hospital by providing data critical for medical diagnosis. For example, in a motor vehicle collision, noting the degree of intrusion into the passenger compartment, deployment of airbags or use of seatbelts can help guide treatment later in the hospital. Your prehospital documentation also supports your rationale for treatment decisions, verifies protocol adherence, and could be used as evidence should testimony about an episode of care be necessary.
Structure[edit | edit source]
The EMS PCR record should include:
- Patient demographics such as name, address, date of birth, age, and gender.
- Dispatch data, such as the location of the call and times related to the call such as time on scene for rescuers and first responders.
- Provider's initial impression of the patient and the scene including details on the mechanism of injury.
- Patient specific care information such as:
- Patient's chief complaint
- Level of Consciousness (on the AVPU scale) or mental status (Alertness and Orientation)
- Baseline and trending vital signs throughout the transport
- Pertinent medical history in the SAMPLE format
- The results from both quick and complete physical exams
- Interventions performed on the patient, including the time those interventions were initiated
- The results of performed interventions
- Documentation of any refusal of care or transport
- Transfer of care to next level of care including the facility, name of the staff member to whom the patient was handed off, and the time.
Format and Execution[edit | edit source]
These records may be organized in many different formats. Many agencies use pre-printed standardized forms with both check boxes and areas for narrative descriptions for hand written documents, or mobile electronic data entry systems for feeding data directly into integrated Electronic Health Records (EHRs). Whatever the format, the PCR is only as good as the information entered into it. The information is vitally important for many aspects of patient care beyond the scene so it is critical that you document everything in the clearest manner possible:
- Patient data and notes should be complete and organized in a consistent manner. Two popular methods are the SOAP Note (Subjective, Objective, Assessment and Plan) or the CHART Method (Chief complaint, History and physical examination, Assessment, Treatment (Rx) and Transport).
- All times should be recorded in 24hr military time
- For hand-written notes, black or blue ink is preferred
- Errors should be corrected with a single line through the incorrect word or number and the correct number written next to it and initialed by the provider
- Information included in one section of the PCR does not need to be included into the narrative. Repeated information bears with it the possibility of misreporting (BG 120 in the Vitals section but BG 1200 in the narrative).
Legal Aspects[edit | edit source]
Thorough PCRs help support the medical diagnosis, provide a rationale for treatment decisions in the field, and demonstrate that responders adhered to their local protocols. Complete documentation is the best defense should there ever be litigation around a poor outcome.
Failure to document can lead to questions regarding the appropriateness of care, and whether treatments within the standard of care were negligently omitted. Negligence is a strict legal test in which all of the following are found to be true:
- There was a duty to act
- There was a breach of that duty
- There was injury to a patient
- The injury was caused by the breach
For example, in a situation where, according to protocols and the scope of practice of the EMS, a particular intervention such as C-spine precautions was called for (a duty to act), if there is no record of C-spine precautions being initiated and maintained (a breach of that duty) in a patient who is found to be paralyzed (injury) secondary to a spinal injury (arguably caused by the failure to maintain C-spine precautions), a jury is likely to determine negligence occurred - even if C-spine precautions were taken.
If it isn't documented, it didn't happen. If it isn't documented, you can be found negligent for not doing it whether or not it was done.
Documenting Refusal of care[edit | edit source]
Refusal of care is a common source of litigation in Emergency Services. While every mentally competent adult is legally able to refuse care, many factors from anticipated costs, to personal legal status, to fear of retaliation in domestic violence situations can influence a patient to refuse care in a situation that puts their wellbeing or even their life at risk. Especially when external factors may be present, it is important to offer the patient alternatives and to enlist bystanders and family in attempts to persuade the patient to accept care. Refusal must be explored carefully with a patient, documented, and added to their PCR to prevent it from later being considered abandonment.
Components of a thorough patient refusal document include documenting that you have done all of the following:
- Performed a complete assessment that indicates the patient is competent to make a rational, informed decision
- Clearly described the recommendation for care/transport
- Verified that the patient can articulate an understanding of their condition and the potential consequences of treatment refusal with the discussed consequences clearly noted in the refusal document.
- Have enlisted family or bystanders to encourage the patient to seek care.
- Have offered reasonable alternatives to the recommended treatment/transport (i.e. having family member drive patient to the hospital, going to see their primary care doctor)
- Have explained that you are willing to return if the patient changes his or her mind
- Had the patient sign the refusal form with the above documented
- Had a family member, police officer or bystander sign the refusal form as a witness. If the patient refuses to sign, have the witness note that with their signature.
Patients may, of course, be willing to be evaluated and transported by EMS but refuse care during transport. Refusal of specific care should be documented with as much care as full refusal. Patients may not feel as though they need a cervical collar or IV, and sometimes the EMT is unable to convince the patient of the benefits of care. Explaining the risks of refusing/benefits of care to the patient and obtaining a signature releasing EMS from liability in the case that withholding of care causes damage to the patient is incredibly important if you want to avoid expensive and potentially career threatening lawsuits. Competent patients may refuse any or all care provided by EMS.
Special Reporting Situations[edit | edit source]
As an EMT in the US you are a mandated reporter for child/adult/elder abuse. This means that you are legally obliged to make a report to Child/Adult Protective Services if you believe on reasonable grounds that a child is in need of protection from physical injury or sexual abuse, and to make the report as soon as practicable after forming your belief.
Other situations such as incidents involving gunshot wounds, dog bites, certain infectious diseases, or suspected physical or sexual abuse (especially in vulnerable populations) also require filing special reports with appropriate authorities.
Learn your local requirements and channels for reporting.
Tips and Tricks[edit | edit source]
- Limit potential perjury. The PCR is a legal document, so stating that a patient is GCS 15 when you state that they are confused earlier on is technically lying and could be used to undermine your PCR if it is brought to court. The narrative should provide a picture of the scene and treatments provided/justification for treatments without including any of the raw "data" found in the rest of the PCR. Think of the narrative like a story that the receiving physician is reading to get an understanding of what is going on. A lay person should be able to read a narrative and have some peripheral idea of what was going on on scene and during transport. If "data" is needed in the narrative, double check that it matches the "data" found in the rest of the PCR.
- Mistakes in charting commonly occur in situations where the provider routinely contacts similar patients (i.e. most urban EMS systems). Not every patient is critical, or even requires ambulance transport and providers can get complacent on their PCRs. Stating that your major trauma patient with 12 GSWs to the chest has "no obvious life threats or bleeding" because it is in every other PCR and you have not slept for 16 hours is still lying on a legal document. Have your partner read PCRs on critical calls, especially when you are starting out; this will reduce errors significantly due to the extra set of eyes.
Additional Resources[edit | edit source]
- Example patient care report narratives may be found here.