patient care records versus prehospital care report

by Kirk Sipes 8 min read

Prehospital Patient Care Report - IHE Wiki

34 hours ago Define Prehospital patient care report. or "PPCR" means a document used to summarize the facts and events of an EMS incident and includes, but is not limited to, the type of medical emergency or nature of the call, the response time, the treatment provided and other minimum data items as prescribed by the board. "PPCR" includes any supplements, addenda, or other related … >> Go To The Portal


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.

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:

Is documentation an essential part of all prehospital care?

POLICY STATEMENT Supersedes/Updates: 85-01, 96-01, 02-05 No. 12 - 02 Date: 1/23/2012 Re: Prehospital Care Reports (PCRs) Page 1 of 5 Documentation is an essential part of all prehospital medical care.

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.

What is a prehospital care report?

(prē-hos'pi-tăl kār rĕ-pōrt') An electronic or written report completed by a prehospital provider that contains demographic and medical information as well as a record of the treatment and transport of a patient.

What's the difference between prehospital and inhospital?

As adjectives the difference between hospital and prehospital. is that hospital is (obsolete) hospitable while prehospital is before a patient is brought to a hospital.

What are the methods of documentation in prehospital care?

Prehospital documentation is used for different purposes....Vital SignsPulse (including the quality and quantity)Respirations (including the quality and quantity)Blood pressure.Pulse oximetry.Glasgow Coma Scale.Pain level/scale.

What should be included in the prehospital assessment?

PEMS system capacity to handle common emergency conditions including acute chest pain, traumatic injury, obstetric emergencies, and respiratory distress would be assessed using infrastructure checklists. Checklist components would cover equipment, supplies, protocols, and personnel basic knowledge of these conditions.

Why is prehospital care important?

The realisation that, particularly in the case of trauma, the less the prehospital time, the better the outcome, has resulted in the shortening of on scene times, reduction in time consuming on scene procedures, and rapid transport, utilising in transit resuscitation.

What is the most important reason for administering a Prehospital Stroke Scale?

Medical responders could identify people with stroke more accurately if they use checklists called stroke recognition scales. Such scales include symptoms and other readily‐available information. A positive result on the scale indicates high risk of stroke and the need of urgent specialist assessment.

What is patient care report?

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. The documentation included on the PCR provides vital information, which is necessary for continued care at the hospital.

What are the elements of a patient care report?

There are seven elements (at a minimum) that we have identified as essential components to documenting a well written and complete narrative.Dispatch & Response Summary. ... Scene Summary. ... HPI/Physical Exam. ... Interventions. ... Status Change. ... Safety Summary. ... Disposition.

What is the difference between the patient information section of the PCR and the administrative information that is included on the PCR?

What is the difference between the patient information section of the PCR and the administrative information that is included on the​ PCR? The patient information includes specific assessment​ findings, and the administrative information includes the trip times.

What are the 5 primary assessments?

the six parts of primary assessment are: forming a general impression, assessing mental status, assessing airway, assessing breathing, assessing circulation, and determining the priority of the patient for treatment and transport to the hospital.

What are the five steps of patient assessment?

emergency call; determining scene safety, taking BSI precautions, noting the mechanism of injury or patient's nature of illness, determining the number of patients, and deciding what, if any additional resources are needed including Advanced Life Support.

What is the difference between the patient information section of the minimum data set and the administrative information that is included on the minimum data set?

What is the difference between the patient information section of the PCR and the administrative information that is included on the​ PCR? The patient information includes specific assessment​ findings, and the administrative information includes the trip times.

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.

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.

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.

2. The Problem

There is consensus among the emergency health care community that the widespread adoption of Health Information Technology (HIT) by emergency responders at the scene of a motor vehicle crash holds the promise to improve post-crash care and survivability for crash victims on our nation’s roadways.

3. Key Use Case

1.) A patient is involved in a motor vehicle crash and rendered unconscious.

What are the barriers to adoption of e-PCR?

[13], [14] A 2006 Robert Wood Johnson Foundation report categorized these barriers as financial, organizational, technical, and privacy factors . [13] Table 4 summarizes quotes from our participants expressing similar challenges with e-PCR system adoption along these four dimensions: financial (high start-up costs and lack of financial resources); organizational (lack of leadership and complex organizational structures); technical (poor user interface design and unreliable vendors); and privacy (concerns about privacy and security).

What is a NAEMSP survey?

Study participants were identified in three ways: 1) a web-based survey distributed to all National Association of EMS Physicians (NAEMSP) members; 2) an announcement at the 2010 NAEMSP Annual Meeting; and 3) recommendations from other participants (snowball sampling). [20] NAEMSP is the leading EMS professional organization with a diverse membership, including physicians, paramedics, nurses, administrators, and educators. [21] As leaders of state, regional, or local EMS agencies, these individuals are intimately familiar with medical record operations, including the acquisition and use of e-PCR systems.

What is EMS in healthcare?

The Emergency Medical Services (EMS) system provides out of hospital emergency care to patients with traumatic injuries and medical emergencies from initial 9-1-1 call to dispatch, field response, transport, and handoff to emergency department (ED) staff. A growing body of evidence indicates that high quality EMS care improves patient outcomes. [1], [2] Similar to ambulatory and hospital-based providers, emergency medical technicians and paramedics perform patient assessments and treatment and are required to document their encounters. EMS crews can provide important information to ED staff during patient handoff, such as initial vital signs and the events leading up to the ED visit for unresponsive or confused patients. [3] However, if this handoff is not received in real-time, ED clinicians must track down paper-based run sheets, which can be hard to locate and even more difficult to read.

What is high quality EMS?

A growing body of evidence indicates that high quality EMS care improves patient outcomes. [1], [2] Similar to ambulatory and hospital-based providers, emergency medical technicians and paramedics perform patient assessments and treatment and are required to document their encounters.

What is the challenge of e-PCR?

A key challenge to the adoption, implementation and utilization of e-PCR systems is linkage with ED or hospital information systems. Three participants reported working with their existing community RHIO to electronically exchange e-PCRs. RHIOs are generally non-profit, multi-stakeholder entities that facilitate health information exchange among health care providers in a defined geographic region. [29] Using this established infrastructure, an EMS agency can make a single electronic interface with the RHIO and exchange information with all participating hospitals and physician offices. This is a particularly valuable information exchange strategy for EMS agencies transporting to multiple facilities. The efficiency of this approach was reiterated by a hospital-based emergency medicine physician from the Midwest:

Why adopt e-PCR?

At a time when HIT is a national priority, EMS agencies are highly motivated to adopt e-PCR systems to support quality assurance efforts. They face financial, organizational, technical, and privacy/security issues that are common to many HIT projects as well as additional challenges that are unique to e-PCR system adoption, including fear of increased ambulance run times leading to decreased ambulance availability, difficulty integrating e-PCR systems with existing ED or hospital information systems, and unfunded mandates requiring EMS agency adoption of e-PCR systems. Attention to these challenges of e-PCR system adoption as well as change management principles, such as strong technical skills, project management skills, and people and organizational skills, may also improve the success and value of e-PCR system implementations. Emerging implementation strategies from hospitals, ambulatory practices, and EMS agencies that have overcome these barriers, including using creative funding sources, leveraging existing RHIOs, and building internal IT capacity, may be of use to EMS agencies transitioning to e-PCR systems. Additional empirical studies of the unique challenges to e-PCR systems adoption as well as efforts to facilitate sharing lessons learned from e-PCR system implementations, possibly with support from federal agencies, are urgently needed.

Is e-PCR regulated?

Prehospital care, like other areas of healthcare, is heavily regulated by an array of federal, state, and local policies. Since e-PCR systems can facilitate data management and analysis, some state EMS agencies with administrative purview have used their statutory authority to mandate adoption of e-PCR systems by EMS agencies within their jurisdictions. Participants representing front-line EMS agencies expressed frustration with these mandates, particularly since many states did not provide any resources to support the necessary software, hardware, and training expenses. The mandates were sometimes accompanied by penalties for noncompliance, including loss of license as described by a Midwest medical director:

Actors/Transaction

  • There are two actors in the PPCR profile, the Content Creator and the Content Consumer. Content is created by a Content Creator and is to be consumed by a Content Consumer. The sharing or transmission of content from one actor to the other is addressed by the appropriate use of IHE p…
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Content Consumer Options

  • View Option
    This option defines the processing requirements placed on Content Consumers for providing access, rendering and management of the medical document. See the View Optionin PCC TF-2 for more details on this option. A Content Creator Actor should provide access to a style sheet that …
  • Document Import Option
    This option defines the processing requirements placed on Content Consumers for providing access, and importing the entire medical document and managing it as part of the patient record. See the Document Import Optionin PCC TF-2 for more details on this option.
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Coded Terminologies

  • This profile supports the capability to record entries beyond the IHE required coding associated with structured data. Actors from this profile may choose to utilize coded data, but interoperability at this level requires an agreement between the communicating parties that is beyond the scope of this Profile. To facilitate this level of interoperability, the applications that implement actors w…
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PPCR Content Modules

  • PPCR Module
    The content exchanged shall be structured and coded as required by the PHR Extract Module Content. The Content Creator Actor creates a PHR Extract and shares it with the Content Consumer.
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Grouping with Other Actors

  • Cross Enterprise Document Sharing, Media Interchange and Reliable Messages
    Actors from the ITI XDS, XDM and XDR profiles embody the Content Creator and Content Consumer sharing function of this profile. A Content Creator or Content Consumer may be grouped with appropriate actors from the XDS, XDM or XDR profiles to exchange the content de…
  • Document Digital Signature
    Content Creator actors should digitally sign all documents using the Digital Signature (DSG) Content Profile. Content Consumer actors should verify the Digital Signature of the submission set before use of the information it contains.
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Requirements of PPCR Actors

  • This section describes the specific requirements for each Actor defined within this profile. Specific details can be found in Volume 1 and Volume 2 of the technical framework.
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