Procedure 40 EMS Electronic Patient Care Record (ePCR) 05/03/2024

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Questions and Answers

What is required to be completed for every patient involved in a 911 call?

A verbal report to the OIC

An ePCR for every 911 call, regardless of treatment (correct)

Only ePCRs for emergency cases

An ePCR only if the patient is transported

Which of the following is NOT a mandatory element when completing an ePCR?

Crew Members

Unit

Patient History (correct)

Shift

What must be done at the beginning of every shift change concerning ePCR devices?

Collect all previous ePCRs

Power Off and restart the devices (correct)

Log out of all devices

Install a new version of MetroPCR

If a 911 call is made but the patient refuses evaluation or transport, what is still required?

An ePCR report must still be completed Signup and view all the answers

What should be confirmed or selected within the MetroPCR application before reporting?

Correct unit designator as identified within CAD Signup and view all the answers

What format is required for entering the LifePak 15 serial number in the ePCR?

LP15######## Signup and view all the answers

Who is responsible for performing a 'Sign Out' in the MetroPCR application?

The OIC at change of shift Signup and view all the answers

When a new crew member joins the unit, what action must be taken in the MetroPCR application?

Add the new crew member and modify staffing Signup and view all the answers

What should be done if the patient's SSN cannot be obtained?

Use the symbol to indicate it's not available Signup and view all the answers

In the situation where a patient has a cardiac arrest, which data should be entered if known?

The date and time of the cardiac arrest Signup and view all the answers

What must be indicated if resuscitation efforts were discontinued?

The reason CPR was stopped Signup and view all the answers

Which of the following is NOT a required field when documenting the patient's information?

Patient’s Email Address Signup and view all the answers

If an AED was used prior to EMS arrival, which detail must be provided?

Who first applied the AED Signup and view all the answers

When selecting the Primary Method of Payment, which option is relevant in case of transport from an MVA?

Auto insurance Signup and view all the answers

What must be entered regarding the patient's employer?

The name of the patient's employer Signup and view all the answers

What is required if the patient's insurance company is not listed in the drop-down?

Select 'Other' and write the name Signup and view all the answers

What must be documented if there was a return of spontaneous circulation after cardiac arrest?

Any return of spontaneous circulation (ROSC) Signup and view all the answers

For accurate recording of a patient's complaint, which aspect should be noted?

The length of time in minutes or hours Signup and view all the answers

Which of the following could be classified as a mechanism of injury?

Automobile collision Signup and view all the answers

What is the appropriate response if a patient's age is not known and no date of birth is provided?

Enter an estimated age with age units Signup and view all the answers

What should be recorded about the first monitored arrest rhythm found in a cardiac arrest case?

The first monitored arrest rhythm Signup and view all the answers

What must be selected when a patient is indicated to have a possible injury?

An appropriate indication of possible injury Signup and view all the answers

What is the primary purpose of documenting the patient's complaints as identified by EMS personnel?

To ensure accurate statistical analysis of medical incidents Signup and view all the answers

Which of the following is NOT an essential aspect to document regarding a patient's narrative?

The patient's favorite food Signup and view all the answers

In what scenario would the 'Symptom Not Present' button be utilized?

To indicate associated symptoms that were not experienced Signup and view all the answers

If a patient reports a pain level of 5 on a scale from 1 to 10, how should this be interpreted?

The pain is moderate Signup and view all the answers

What is the role of the Officer in Charge when a crew member is absent due to training?

They are the first person added to the crew list. Signup and view all the answers

When must manual entry of data occur in the CAD system?

If a CAD push is not received or is missing information. Signup and view all the answers

Which of the following details is essential in determining the patient's last known well status?

The date and time provided by the patient or witnesses Signup and view all the answers

Which element must always be manually entered for reporting?

At Patient Time Signup and view all the answers

What information should be included when selecting the primary organ system for a medical complaint?

The organ system with the most prevalent symptoms Signup and view all the answers

What choice is NOT included in the Service Requested options?

Transitional Care Signup and view all the answers

When recording a patient's medical history, which factor is LEAST likely to be pertinent?

Family members’ health habits Signup and view all the answers

What is required if an event is marked as a Mass Casualty Incident?

Additional elements related to triage need to be selected. Signup and view all the answers

Which of the following should EMS personnel document when assessing a pain-related symptom?

Specific characteristics of the pain Signup and view all the answers

In the context of advanced directives, what does a valid State of Florida Do Not Resuscitate Order (DNRO) signify?

A legal indication to withhold resuscitation efforts by EMS Signup and view all the answers

What happens if the Crew on an Open report needs to be modified?

It must be done from the Crew section in the navigation panel. Signup and view all the answers

What does the Unit Call Sign correspond to?

The EMS unit number used for communication. Signup and view all the answers

Which factor should NOT influence the assessment of barriers to patient care?

The patient’s insurance status Signup and view all the answers

When EMS personnel select a pain quality for a patient, which of the following terms is inappropriate?

Happy Signup and view all the answers

Which option represents a non-emergent response?

Standby Signup and view all the answers

What must be ensured when employing narrative templates for patient reports?

Specific details must be added to ensure uniqueness Signup and view all the answers

What is the default state in the CAD report?

Florida Signup and view all the answers

In which situation is the Last Name field of the Patient required?

It is always required regardless of patient details. Signup and view all the answers

What is the purpose of documenting the ECG attachment method?

To ensure the ECG is properly documented in the report Signup and view all the answers

What information needs to be entered regarding the location of the incident?

Street Address Signup and view all the answers

Why is it important to assess a patient's medications during care?

To anticipate potential interactions with administered treatments Signup and view all the answers

Which time entry does not require manual input during a CAD report?

Dispatched Signup and view all the answers

What is captured by the Apt, Suite or Room field?

Specific details of the address where the incident occurred. Signup and view all the answers

What must be selected regarding delays associated with the EMS event?

Type of Response Delay Signup and view all the answers

Which component is crucial for documenting the patient's heart assessment findings?

Heart sounds assessment Signup and view all the answers

What must be done after selecting 'Normal' in the Assessments section?

Auto-close each entry and proceed to the next question Signup and view all the answers

Which vital sign method is used to determine the patient's heart rate?

Auscultated Signup and view all the answers

When documenting the patient's respiratory effort, under which category is this recorded?

Vitals Signup and view all the answers

What does the FAST-ED Stroke Assessment require after selecting 'Yes'?

Completion of specific questions related to the assessment Signup and view all the answers

Which blood pressure reading is always required to complete the vital signs documentation?

Both systolic and diastolic blood pressure Signup and view all the answers

What information is necessary about the patient's abdomen during the assessment?

Location and specific assessment findings Signup and view all the answers

What should be recorded if a vital sign cannot be obtained?

The 'No' symbol Signup and view all the answers

What detail is essential when entering the assessment findings for the patient's eye?

Both location and assessment findings Signup and view all the answers

For the Glasgow Coma Score, which components need to be documented?

Eye, verbal, and motor responses Signup and view all the answers

Which assessment is specifically associated with signs of stroke-like symptoms?

Stroke score Signup and view all the answers

Which of these assessments includes the requirement of documenting temperature?

Vitals Signup and view all the answers

For the Carbon Monoxide (CO) evaluation, what percentage is recorded for a 'High' reading?

600% Signup and view all the answers

What is the primary purpose of the procedure section in the report?

To enter all procedures performed on the patient Signup and view all the answers

What is required when a patient refuses to provide a signature after evaluation?

A witness signature must be obtained. Signup and view all the answers

When a witness signature is needed, which of the following is NOT acceptable?

A crew member who is the report author signing. Signup and view all the answers

What must be documented if a patient signature cannot be obtained?

Details of why the signature was unavailable. Signup and view all the answers

What is a required element when capturing a signature in the ADD Signature Form?

The reason for the individual’s signature. Signup and view all the answers

What does the routine practice of using 'Patient Contaminated' as a reason for no signature indicate?

Signatures must still be obtained despite contamination. Signup and view all the answers

What should be selected if a patient is not able to sign but a non-MDFR witness is available?

Witness Signer type. Signup and view all the answers

Why is accurate documentation of every call considered critical?

It serves as legal proof of actions taken. Signup and view all the answers

How should issues with the ePCR application be addressed?

Contact the EMS Field Supervisor or call the hotline. Signup and view all the answers

What does the disposition 'Cancelled on Scene' indicate about the EMS unit's actions?

The unit arrived on-scene but was cancelled without patient contact. Signup and view all the answers

Which of the following accurately describes the requirement for documenting medications administered by the EMS unit?

Date/time, medication, route, dosage, and response must be documented. Signup and view all the answers

What is meant by 'Suspected Reasons for Failure' in airway management?

The potential causes for unsuccessful airway management. Signup and view all the answers

What does 'Prior to this Unit’s Care' indicate when documenting procedures?

The procedure was conducted before the EMS unit began care. Signup and view all the answers

What should be documented regarding the 'Tube Depth' of the airway device?

It needs to be recorded in centimeters at the patient's teeth/lips. Signup and view all the answers

What does the selection 'Complications Encountered' relate to in airway management?

It concerns abnormal effects during airways procedures. Signup and view all the answers

Which option describes the appropriate action when the disposition is 'No Patient Found'?

Document the finding and create a report if a person is present. Signup and view all the answers

In documenting medication administration, which of the following is NOT a required element?

Medication name and intended outcome. Signup and view all the answers

What does the term 'Evaluated and Care Provided' imply in the patient evaluation process?

A patient was evaluated and received EMS treatment. Signup and view all the answers

What action is required if a medication is contraindicated during administration?

Use the 'No' symbol to indicate it was not given. Signup and view all the answers

Which confirmation method is essential for validating the placement of an airway device?

Use of standardized confirmation methods. Signup and view all the answers

What is the significance of documenting the 'Crew Member ID' during the airway confirmation process?

To facilitate record-keeping and accountability. Signup and view all the answers

What is essential in the reporting of an airway management complication?

All encountered complications must be accurately reported. Signup and view all the answers

Which action is required when the patient's response to medication is negative?

Record the response and note any complications. Signup and view all the answers

What does the code 'Evaluated, No Treatment Required' indicate in the EMS context?

Patient was assessed and deemed not in need of care. Signup and view all the answers

When should 'Refused Evaluation/Treatment and Transport' be recorded?

When a patient declines all forms of care after evaluation. Signup and view all the answers

What is the appropriate action when 'Care/Support Services Refused' occurs?

Document the refusal and return to service without providing care. Signup and view all the answers

What implication does 'Patient Refused Transport' have in an EMS response?

The patient explicitly declines to be transported by EMS. Signup and view all the answers

In what scenario should 'No Transport' be used?

When a lift assist was performed without the need for transport. Signup and view all the answers

What does 'Transport by Another EMS Unit' signify?

Another unit took over after initial care was given by the crew. Signup and view all the answers

Which transport method does 'MDFR Air Rescue' refer to?

A specialized unit for patients requiring air transport. Signup and view all the answers

What is the implication of 'Received Patient from Another EMS Crew'?

Another unit initiated the care which was then continued by the crew. Signup and view all the answers

What should be noted in the narrative when using 'Evaluated and Refused Treatment'?

Details about evaluation and specified treatments refused must be included. Signup and view all the answers

When would 'Support Services Provided' be recorded?

When assistance such as lifting or moving is offered without treating a patient. Signup and view all the answers

Which of the following best describes the code 'Transitional Care Refused'?

Patient refused all forms of monitored care following evaluation. Signup and view all the answers

What must be documented if 'Pre-arrival Activation' is performed?

The date and time of the alert and specific criteria used. Signup and view all the answers

When selecting 'Position of Patient During Transport', which situation does NOT require documentation?

When the patient remained in a seated position without changes. Signup and view all the answers

What does a documented 'Final Patient Acuity' signify?

The patient's condition after the pre-hospital phase of care. Signup and view all the answers

Study Notes

Introduction to ePCR

Mandatory completion of electronic Patient Care Reports (ePCR) for all 911 calls requiring medical assistance.
A “patient” is any individual for whom assistance is requested, regardless of who made the call.
ePCR must be submitted even if the situation is non-emergent or if treatment is refused.
All started ePCR reports must be completed and closed by the end of the Officer in Charge's (OIC) shift.

Crew Change Protocol

ePCR devices should be powered off and restarted during shift changes.
"Sign Out" must be performed to clear previous crew information before new OIC logs in.
Confirm unit designator, shift, transport capabilities, and device serial numbers during setup.
Crew members must be accurately reflected, removing absent personnel and adding them upon return.

CAD Time Entries

Enter critical timestamps for various stages: dispatched, en route, at the scene, and patient.
Manual entries are necessary for times not automatically pushed by CAD, especially "At Patient" time.
Ensure completion of report elements, highlighted in red if CAD data is missing.

Dispatch Information

Must include incident number, type, location, and street address.
City, state, and ZIP code are mandatory, alongside nearby landmarks or mile markers.

Response Data

Identify the EMS unit, shift, service requested, capabilities, and response mode.
Document any response or scene delays comprehensively.
Mass casualty indicators require specific entries, including triage tag color and patient count.

Patient Information Requirements

Mandatory entries include last name, first name, address, SSN, gender, race, birth date, and contact details.
Use symbols if specific information (e.g., SSN) cannot be obtained.

Payment Information

Record primary payment method and detailed insurance information, including policy number and group name.

Patient Situation and Complaint

Document indications of cardiac arrest or possible injury with specific details on cause and mechanism.
Enter complaint types, duration, and associated symptoms, ensuring accurate anatomic location and organ system are selected.
Use narrative section to provide a comprehensive history of the present illness.

Medical History and Medications

Collect pre-existing medical and surgical history; indicate negatives as necessary.
Detail medications, allergies, and immunizations, including dosage and frequency of administration.

Examination and Documentation

Capture patient positioning and ECG attachment methods automatically as required.
Maintain accuracy for all entries, ensuring narratives reflect unique patient encounters for statistical analysis.### ECG Transmission
Select "Photo of ECG" if ECG transmission fails; attach the photo.
ECG must be transmitted and merged into the ePCR whenever required by protocol or documented.

Community Paramedic Referral

Indicate selection for a Community Paramedic Referral when applicable.

Patient Body Weight

Document patient’s estimated or measured body weight in pounds.

Assessment Section

Assessments auto-close upon selecting “Normal”.
Date/Time entry is time-stamped and editable prior to report closure.
Mental, neurological, skin, head, face, neck, heart, pelvis/genitourinary, eye, extremity, chest, lung, spine, abdomen assessments are required.
FAST-ED Stroke Assessment and Sepsis Assessment must also be completed when indicated.

Vitals Collection

Vital signs should include Date/Time, Heart Rate, Blood Pressure (systolic/diastolic), Respiratory Rate, Pulse Oximetry, and Glasgow Coma Score (GCS) components.
Include Body Temperature (F), ETCO2, carbon monoxide levels, and pain score.
Record ECG type, results, and interpretation methods.

Procedures Documentation

Carefully document procedures performed, including Date/Time and detailed observations.
Note any complications or responses associated with procedures.

Airway Management

Indicate clinical indications for invasive airway management and any encountered complications.
Confirmation methods for airway placement must be documented with Date/Time and depth measurement.

Medication Administration

Document Date/Time of medication administration, route, dosage, and response.
Include any complications associated with medication administration.

Patient Disposition

Document the patient disposition such as whether contact was made or care was provided.
Patient Contact can be labeled as made, no contact, cancelled pre- or on-scene, or no patient found.

Transport and Final Patient Acuity

Document details on transport disposition, method, and final patient acuity.
Ensure to indicate the type and reason for transporting to a specific destination.

Pre-arrival Activation

Required for patients meeting STEMI, Stroke, or Trauma Alert criteria, documenting Date/Time and type of alert made prior to arrival.

Signatures and Witnesses

Patient signature is required for evaluated individuals; obtain a witness signature when the patient cannot sign.
Record reason for lack of patient signature and ensure the signature date/time is documented.

Summary

Complete all relevant sections regarding assessments, vitals, procedures, airway management, medication, patient disposition, transport, and necessary signatures to ensure accurate documentation in ePCR.### Documentation Requirements
Accurate and truthful documentation is essential, irrespective of the service level provided.
Patient reports are mandated by Florida Statute and Administrative Code.

Importance of Patient Reports

Reports form part of the patient's permanent medical record.
They can be utilized in litigation and legal proceedings.
Documents actions or inactions and serves as proof of ongoing quality care.

EMS Report Completion

Completion of the EMS Report should not hinder patient management.
All information in the report must be reviewed and finalized before closing.
Reports must be closed by the end of the shift.

Signature Requirements

Signer type must be identified, such as Patient, Patient Representative, Witness, etc.
Status of signature must indicate if it has been collected or if an attempt was made.
Signature capture is necessary for documentation.

Support and Assistance

For ePCR application issues, contact the EMS Field Supervisor.
Alternatively, call the ePCR Hotline at 786-258-0088, which is displayed on the ePCR lock screen.

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Description

This quiz covers the essential procedures for completing an electronic patient care report (ePCR) in accordance with Florida laws and Miami-Dade Fire Rescue protocols. Participants will learn about the requirements for documentation during EMS responses, including definitions and regulations. Understanding ePCR is vital for effective patient care and legal compliance in emergency medical services.