massachusetts ems patient care report

by Daryl Bashirian 6 min read

Office of Emergency Medical Services | Mass.gov

29 hours ago We coordinate local and regional EMS resources to help residents and visitors to the Commonwealth who suffer acute illness or injury and need EMS assistance and transport to hospitals. We certify EMS personnel, license ambulance services, and regulate EMS in Massachusetts. >> Go To The Portal


What is the mission of the Massachusetts Department of EMS?

Our mission is to promote a statewide, community-based emergency medical services (EMS) system. We coordinate local and regional EMS resources to help residents and visitors to the Commonwealth who suffer acute illness or injury and need EMS assistance and transport to hospitals.

What is the Massachusetts ambulance data collection program?

The collection of reliable, comprehensive, valid data from Massachusetts ambulance services allows the Department of Public Health (DPH), ambulance services, and EMS Medical Directors to work collectively to assess the quality of care delivered to patients with the fundamental objective of quality improvement.

What are the statewide treatment protocols in Massachusetts?

The Statewide Treatment Protocols are the standard of EMS patient care in Massachusetts.

What is the primary purpose of EMS data collection?

The primary purpose of EMS data collection is for the improvement and support of EMS systems, research, and delivery of quality patient care.

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What is the purpose of EMS data collection?

The primary purpose of EMS data collection is for the improvement and support of EMS systems, research, and delivery of quality patient care.

How to request MATRIS data?

To request MATRIS data from the Department of Public Health, please complete the MATRIS Data Request Form and email to matrissupport@state.ma.us.

What is a PCR in Boston EMS?

PCRs create a legal record of an ambulance call. It is the responsibility of all personnel to ensure that their PCRs accurately reflect patient information, care given and the medical condition of the patient. To that end, Supervisory personnel or management of Boston EMS may request that staff members modify, amend or fully complete PCRs for a given call when PCR reviews suggest that the information documented may be incorrect or incomplete. Information for each patient call must be complete, accurate, honest and wholly based on the patient's condition. It is legally permissible for staff members to amend PCRs for reasons of completeness, correction, and clarity, and in compliance with the procedures outlined below. Boston EMS does not endorse nor will it tolerate any staff member who embellishes or falsifies medical necessity, mileage, services rendered, supplies used or any other information for the purpose of obtaining or enhancing reimbursement.

What should be included in a PCR?

Pertinent negatives should be documented on all assessment questions asked. The completed PCR should include a description of all procedures, interventions, or medications provided as well as the time they were performed, by whom, and any resulting changes in the patient’s status.

Do ambulances have to complete PCR?

Unless cancelled prior to arrival on scene, responding ambulance crews are required to complete a Patient Care Report (PCR) for each response . The PCR should include all applicable information about the EMS response it documents. In cases where there are multiple patients involved in the same incident, a PCR must be completed for each patient.

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Thanks for joining us!

Today marks the first in our Documentation 101 blog series. Using the next several blog postings, we’ll be attempting to put together a few coaching blogs to help all of you become better EMS documenters.

Maybe you need some basic writing help?

There’s nothing wrong in admitting that you need help. You can even better yourself, personally, by learning to communicate in writing more effectively. There are tons of self-help tools on the Internet to assist you with writing and grammar skills.

To the Rescue!

We’re not finished. As part of this documentation series, we’ll include some specific steps to make you a better documenter. Make your goal to be the best documenter that your department has and you’re well on your way to PCR writing success.

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What Is a Patient Care Report?

We often hear of care reports based on by medical teams or by medical authorities. Yet, we are not sure how this differs from the kind of report that is given to us by the same people. So this is the time to make it as clear as possible.

How to Write a Patient Care Report?

Where do you even begin when you write a patient care report? A lot of EMS or EMTs do know how to write one since they are trained to do so.

What is a patient care report?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the information necessary for the assessment and evaluation of a patient’s care.

What should not be written in a patient care report?

What should be avoided in a patient care report is making up the information that is not true to the patient. This is why you have to be very careful and very meticulous when writing these kinds of reports. Every detail counts.

Who is in charge of reading the patient care report?

The person or the people who will be reading the report are mostly medical authorities. When you are going to be passing this kind of report, make sure that you have all the information correctly. One wrong information can cause a lot of issues and problems.

Paper Patient Care Report (PCR)

Here is an example of two versions of print out, paper PCR you can download and use in your service.

Electronic Patient Care Report (ePCR)

The state of Alaska provids a free ePCR (Electronic Patient Care Report) system allowing communities to customize their run report forms to match their specific community needs.

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