virginia patient care report short form

Is a patient care report a medical record?

The patient care report is both a medical record and a legal document. This form becomes the documentation by which the prehospital care provider can substantiate the situation encountered, the care provided for the patient and that they acted within the scope of their certification and training.

What is the pre-hospital patient data report?

The Pre-hospital Patient Data Report (PPDR) is a supplemental sheet to the PPCR form and is one of the available mechanisms for reporting the minimum data set to the Office of EMS. Agencies who develop their own PPCR form may also use the PPDR as a supplemental sheet to submit the minimum data set to Office of EMS.

How do I provide a form to the examining physician?

INSTRUCTIONS: Please provide a copy of this form to each employee to be given to his/her examining physician. The top portion of the form should be completed by the employee; the bottom portion must be completed and signed by the physician, physician's assistant, or licensed nurse practitioner.

What are the regulations for EMS agencies in Virginia?

INTRODUCTION Each EMS agency operating in Virginia must comply with the specifications of section 32.1– 116.1 of the Code of Virginia.

How do you write 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 pre hospital care report?

The prehospital care report is used to record patient data. The data can include patient demographics such as name, address, date of birth, age, and gender. Dispatch data, such as the location of the call, times related to the call, rescuers and first responders on the scene may be included.

What is electronic patient care report?

An electronic patient care record (ePCR) is a digital document containing key patient information, assessments, treatments, narrative, and signatures. Before ePCRs arriving on scene, EMS agencies, ambulances, and fire departments documented call data on paper.

What is a patient care report used for?

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 is a PCR document?

The PCR documentation is considered a medical document that becomes part of the patient's permanent medical record. It is also considered a legal document in cases where liability and/or malpractice issues arise. It is the source in which all medical billing claims are based.

What is the acronym for PCR in electronic format?

The prehospital care report or PCR (also ePCR when in the electronic format) serves as the only record of each individual patient contact, treatment, transportation, or cancellation of services within each EMS service.

How do you write a good PCR?

How to Write an Effective ePCR NarrativeBe concise but detailed. Be descriptive in explaining exactly what happened and include the decision-making process that led to the action. ... Present the facts in clear, objective language. ... Eliminate incorrect grammar and other avoidable mistakes. ... Be consistent and thorough.

What is a patient care form?

Patient care report or “PCR” means a report that documents the assessment and management of the patient by the emergency care provider.

What is soap EMT?

The Subjective, Objective, Assessment and Plan (SOAP) note is an acronym representing a widely used method of documentation for healthcare providers. The SOAP note is a way for healthcare workers to document in a structured and organized way.[1][2][3]

Administrative Code

Table of Contents » Title 12. Health » Agency 5. Department Of Health » Chapter 31. Virginia Emergency Medical Services Regulations » Part II. EMS Agency, EMS Vehicle and EMS Personnel Standards » Article 1. EMS Agency Licensure and Requirements » 12VAC5-31-560. Patient care records.

12VAC5-31-560. Patient care records

A. An original PPCR shall specifically identify by name the personnel who meet the staffing requirements of the EMS vehicle.

Administrative Code

Table of Contents » Title 12. Health » Agency 5. Department Of Health » Chapter 31. Virginia Emergency Medical Services Regulations » Part II. EMS Agency, EMS Vehicle and EMS Personnel Standards » Article 5. EMS Personnel Requirements and Standard of Conduct » 12VAC5-31-1140. Provision of patient care documentation.

12VAC5-31-1140. Provision of patient care documentation

EMS personnel and EMS agencies shall provide the receiving medical facility or transporting EMS agency with a copy of the prehospital patient care report for each patient treated at the time of patient transfer.