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A patient care report is a document written by medical professionals to report about the patient’s wellbeing, care and status. This document consists of the result of the assessment and the evaluation of the patient being done by the EMTs or the EMS.
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Health information systems for both inpatient and outpatient facilities have a patient registration component used to add new patients to the system as well as to add or edit information about existing patients.
John and Shirlee Colby are bringing their new baby, John, Jr., for his first visit to the pediatrician. Before being seen by the doctor, the new patient must be added to the sys-tem. The parents have completed the paper form shown in Figure 1-11.
Electronic Health Records are the portions of a patient’s medical records that are stored in a com-puter system as well as the functional benefits derived from having an electronic health record.
A goal of using an EHR system is to improve the accuracy and completeness of the patient record. One way to achieve this is to record the information in the EHR at the time it is happening. This is called point-of-care documentation. In a physician’s office, this means completing the encounter note before the patient ever leaves the office. In an inpatient setting, this means that nurses enter vital signs and nursing notes at bedside, not at the end of their shift.
In Electronic Health Records: Changing the Vision, authors Murphy, Waters, Hanken, and Pfeiffer define the EHR to include “any information relating to the past, present or future physical/mental health, or condition of an individual which resides in electronic sys-tem(s) used to capture, transmit, receive, store, retrieve, link and manipulate multimedia data for the primary purpose of providing healthcare and health-related services.”3
The Health Insurance Portability and Accountability Act (HIPAA), which will be covered in Chapter 11, did not define an EHR, but perhaps the HIPAA Security Rule broadened the definition. The Security Rule established protection for all personally identifiable health information stored in electronic format. Thus, everything about a patient stored in a healthcare provider’s system is protected and treated as part of the patient’s EHR. HIPAA also standardized transaction formats for several Administrative Processes identified in the IOM report.
The response to the IOM report on the rate of preventable medical errors was swift and positive, within both the government and private sectors. Almost immediately, Presi-dent Bill Clinton’s administration issued an executive order instructing government agencies that conduct or oversee healthcare programs to implement proven techniques for reducing medical errors and creating a task force to find new strategies for reducing errors. Congress appropriated $50 million to the Agency for Healthcare Research and Quality (AHRQ) to support a variety of efforts targeted at reducing medical errors.
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.
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.
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 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.
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.
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