new york patient care report

Pre-hospital Care Reports are medical records, and are confidential under Federal and New York State law and therefore FDNY follows specific guidance to ensure that patients’ records are confidential and only released to the patient or as required by law. In order to obtain the records, the patient must complete an FDNY HIPAA Authorization form.

Full Answer

What is the New York patient occurrence reporting and tracking system?

The New York Patient Occurrence Reporting and Tracking System (NYPORTS) is a mandatory adverse event reporting system established pursuant to Public Health Law 2805-l and Title 10 New York Code, Rules and Regulations 405.8 and 751.10. As an adverse event reporting system, NYPORTS is not specifically designed to capture medical errors exclusively.

What should be included in a patient care report?

It must include, but not be limited to the documentation of the event or incident, the medical condition, treatment provided and the patient’s medical history. The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool.

When must a prehospital care report be completed?

(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; Title 10 NYCRR Part 800.21:

What are prehospital care reports (PCRs)?

Re: Prehospital Care Reports (PCRs) Page 1 of 5 Documentation is an essential part of all prehospital medical care. It must include, but not be limited to the documentation of the event or incident, the medical condition, treatment provided and the patient’s medical history.

How often do you submit PCRs for ambulance?

PCRs shall be submitted at least monthly, or more often if so indicated by the program agency.

What is the confidentiality of health information?

Maintaining confidentiality is an essential part of all health 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.

What is a PCR/EPCR?

The PCR/ePCR 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/ePCR simply at the request of a law enforcement or other agency. If a copy of the PCR/ePCR 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. PCR/ePCR must be made available for inspection to properly identified employees of the NYS Department of Health.

Do EMS have to leave PCR?

EMS services are required to leave a paper copy or transfer the electronic PCR information to the hospital prior to the EMS service leaving the hospital. This document must minimally include, patient demographics, presenting problem, assessment findings, vital signs, and treatment rendered.