Podcast
Questions and Answers
What is required to be completed for every patient involved in a 911 call?
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?
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?
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?
If a 911 call is made but the patient refuses evaluation or transport, what is still required?
What should be confirmed or selected within the MetroPCR application before reporting?
What should be confirmed or selected within the MetroPCR application before reporting?
What format is required for entering the LifePak 15 serial number in the ePCR?
What format is required for entering the LifePak 15 serial number in the ePCR?
Who is responsible for performing a 'Sign Out' in the MetroPCR application?
Who is responsible for performing a 'Sign Out' in the MetroPCR application?
When a new crew member joins the unit, what action must be taken in the MetroPCR application?
When a new crew member joins the unit, what action must be taken in the MetroPCR application?
What should be done if the patient's SSN cannot be obtained?
What should be done if the patient's SSN cannot be obtained?
In the situation where a patient has a cardiac arrest, which data should be entered if known?
In the situation where a patient has a cardiac arrest, which data should be entered if known?
What must be indicated if resuscitation efforts were discontinued?
What must be indicated if resuscitation efforts were discontinued?
Which of the following is NOT a required field when documenting the patient's information?
Which of the following is NOT a required field when documenting the patient's information?
If an AED was used prior to EMS arrival, which detail must be provided?
If an AED was used prior to EMS arrival, which detail must be provided?
When selecting the Primary Method of Payment, which option is relevant in case of transport from an MVA?
When selecting the Primary Method of Payment, which option is relevant in case of transport from an MVA?
What must be entered regarding the patient's employer?
What must be entered regarding the patient's employer?
What is required if the patient's insurance company is not listed in the drop-down?
What is required if the patient's insurance company is not listed in the drop-down?
What must be documented if there was a return of spontaneous circulation after cardiac arrest?
What must be documented if there was a return of spontaneous circulation after cardiac arrest?
For accurate recording of a patient's complaint, which aspect should be noted?
For accurate recording of a patient's complaint, which aspect should be noted?
Which of the following could be classified as a mechanism of injury?
Which of the following could be classified as a mechanism of injury?
What is the appropriate response if a patient's age is not known and no date of birth is provided?
What is the appropriate response if a patient's age is not known and no date of birth is provided?
What should be recorded about the first monitored arrest rhythm found in a cardiac arrest case?
What should be recorded about the first monitored arrest rhythm found in a cardiac arrest case?
What must be selected when a patient is indicated to have a possible injury?
What must be selected when a patient is indicated to have a possible injury?
What is the primary purpose of documenting the patient's complaints as identified by EMS personnel?
What is the primary purpose of documenting the patient's complaints as identified by EMS personnel?
Which of the following is NOT an essential aspect to document regarding a patient's narrative?
Which of the following is NOT an essential aspect to document regarding a patient's narrative?
In what scenario would the 'Symptom Not Present' button be utilized?
In what scenario would the 'Symptom Not Present' button be utilized?
If a patient reports a pain level of 5 on a scale from 1 to 10, how should this be interpreted?
If a patient reports a pain level of 5 on a scale from 1 to 10, how should this be interpreted?
What is the role of the Officer in Charge when a crew member is absent due to training?
What is the role of the Officer in Charge when a crew member is absent due to training?
When must manual entry of data occur in the CAD system?
When must manual entry of data occur in the CAD system?
Which of the following details is essential in determining the patient's last known well status?
Which of the following details is essential in determining the patient's last known well status?
Which element must always be manually entered for reporting?
Which element must always be manually entered for reporting?
What information should be included when selecting the primary organ system for a medical complaint?
What information should be included when selecting the primary organ system for a medical complaint?
What choice is NOT included in the Service Requested options?
What choice is NOT included in the Service Requested options?
When recording a patient's medical history, which factor is LEAST likely to be pertinent?
When recording a patient's medical history, which factor is LEAST likely to be pertinent?
What is required if an event is marked as a Mass Casualty Incident?
What is required if an event is marked as a Mass Casualty Incident?
Which of the following should EMS personnel document when assessing a pain-related symptom?
Which of the following should EMS personnel document when assessing a pain-related symptom?
In the context of advanced directives, what does a valid State of Florida Do Not Resuscitate Order (DNRO) signify?
In the context of advanced directives, what does a valid State of Florida Do Not Resuscitate Order (DNRO) signify?
What happens if the Crew on an Open report needs to be modified?
What happens if the Crew on an Open report needs to be modified?
What does the Unit Call Sign correspond to?
What does the Unit Call Sign correspond to?
Which factor should NOT influence the assessment of barriers to patient care?
Which factor should NOT influence the assessment of barriers to patient care?
When EMS personnel select a pain quality for a patient, which of the following terms is inappropriate?
When EMS personnel select a pain quality for a patient, which of the following terms is inappropriate?
Which option represents a non-emergent response?
Which option represents a non-emergent response?
What must be ensured when employing narrative templates for patient reports?
What must be ensured when employing narrative templates for patient reports?
What is the default state in the CAD report?
What is the default state in the CAD report?
In which situation is the Last Name field of the Patient required?
In which situation is the Last Name field of the Patient required?
What is the purpose of documenting the ECG attachment method?
What is the purpose of documenting the ECG attachment method?
What information needs to be entered regarding the location of the incident?
What information needs to be entered regarding the location of the incident?
Why is it important to assess a patient's medications during care?
Why is it important to assess a patient's medications during care?
Which time entry does not require manual input during a CAD report?
Which time entry does not require manual input during a CAD report?
What is captured by the Apt, Suite or Room field?
What is captured by the Apt, Suite or Room field?
What must be selected regarding delays associated with the EMS event?
What must be selected regarding delays associated with the EMS event?
Which component is crucial for documenting the patient's heart assessment findings?
Which component is crucial for documenting the patient's heart assessment findings?
What must be done after selecting 'Normal' in the Assessments section?
What must be done after selecting 'Normal' in the Assessments section?
Which vital sign method is used to determine the patient's heart rate?
Which vital sign method is used to determine the patient's heart rate?
When documenting the patient's respiratory effort, under which category is this recorded?
When documenting the patient's respiratory effort, under which category is this recorded?
What does the FAST-ED Stroke Assessment require after selecting 'Yes'?
What does the FAST-ED Stroke Assessment require after selecting 'Yes'?
Which blood pressure reading is always required to complete the vital signs documentation?
Which blood pressure reading is always required to complete the vital signs documentation?
What information is necessary about the patient's abdomen during the assessment?
What information is necessary about the patient's abdomen during the assessment?
What should be recorded if a vital sign cannot be obtained?
What should be recorded if a vital sign cannot be obtained?
What detail is essential when entering the assessment findings for the patient's eye?
What detail is essential when entering the assessment findings for the patient's eye?
For the Glasgow Coma Score, which components need to be documented?
For the Glasgow Coma Score, which components need to be documented?
Which assessment is specifically associated with signs of stroke-like symptoms?
Which assessment is specifically associated with signs of stroke-like symptoms?
Which of these assessments includes the requirement of documenting temperature?
Which of these assessments includes the requirement of documenting temperature?
For the Carbon Monoxide (CO) evaluation, what percentage is recorded for a 'High' reading?
For the Carbon Monoxide (CO) evaluation, what percentage is recorded for a 'High' reading?
What is the primary purpose of the procedure section in the report?
What is the primary purpose of the procedure section in the report?
What is required when a patient refuses to provide a signature after evaluation?
What is required when a patient refuses to provide a signature after evaluation?
When a witness signature is needed, which of the following is NOT acceptable?
When a witness signature is needed, which of the following is NOT acceptable?
What must be documented if a patient signature cannot be obtained?
What must be documented if a patient signature cannot be obtained?
What is a required element when capturing a signature in the ADD Signature Form?
What is a required element when capturing a signature in the ADD Signature Form?
What does the routine practice of using 'Patient Contaminated' as a reason for no signature indicate?
What does the routine practice of using 'Patient Contaminated' as a reason for no signature indicate?
What should be selected if a patient is not able to sign but a non-MDFR witness is available?
What should be selected if a patient is not able to sign but a non-MDFR witness is available?
Why is accurate documentation of every call considered critical?
Why is accurate documentation of every call considered critical?
How should issues with the ePCR application be addressed?
How should issues with the ePCR application be addressed?
What does the disposition 'Cancelled on Scene' indicate about the EMS unit's actions?
What does the disposition 'Cancelled on Scene' indicate about the EMS unit's actions?
Which of the following accurately describes the requirement for documenting medications administered by the EMS unit?
Which of the following accurately describes the requirement for documenting medications administered by the EMS unit?
What is meant by 'Suspected Reasons for Failure' in airway management?
What is meant by 'Suspected Reasons for Failure' in airway management?
What does 'Prior to this Unit’s Care' indicate when documenting procedures?
What does 'Prior to this Unit’s Care' indicate when documenting procedures?
What should be documented regarding the 'Tube Depth' of the airway device?
What should be documented regarding the 'Tube Depth' of the airway device?
What does the selection 'Complications Encountered' relate to in airway management?
What does the selection 'Complications Encountered' relate to in airway management?
Which option describes the appropriate action when the disposition is 'No Patient Found'?
Which option describes the appropriate action when the disposition is 'No Patient Found'?
In documenting medication administration, which of the following is NOT a required element?
In documenting medication administration, which of the following is NOT a required element?
What does the term 'Evaluated and Care Provided' imply in the patient evaluation process?
What does the term 'Evaluated and Care Provided' imply in the patient evaluation process?
What action is required if a medication is contraindicated during administration?
What action is required if a medication is contraindicated during administration?
Which confirmation method is essential for validating the placement of an airway device?
Which confirmation method is essential for validating the placement of an airway device?
What is the significance of documenting the 'Crew Member ID' during the airway confirmation process?
What is the significance of documenting the 'Crew Member ID' during the airway confirmation process?
What is essential in the reporting of an airway management complication?
What is essential in the reporting of an airway management complication?
Which action is required when the patient's response to medication is negative?
Which action is required when the patient's response to medication is negative?
What does the code 'Evaluated, No Treatment Required' indicate in the EMS context?
What does the code 'Evaluated, No Treatment Required' indicate in the EMS context?
When should 'Refused Evaluation/Treatment and Transport' be recorded?
When should 'Refused Evaluation/Treatment and Transport' be recorded?
What is the appropriate action when 'Care/Support Services Refused' occurs?
What is the appropriate action when 'Care/Support Services Refused' occurs?
What implication does 'Patient Refused Transport' have in an EMS response?
What implication does 'Patient Refused Transport' have in an EMS response?
In what scenario should 'No Transport' be used?
In what scenario should 'No Transport' be used?
What does 'Transport by Another EMS Unit' signify?
What does 'Transport by Another EMS Unit' signify?
Which transport method does 'MDFR Air Rescue' refer to?
Which transport method does 'MDFR Air Rescue' refer to?
What is the implication of 'Received Patient from Another EMS Crew'?
What is the implication of 'Received Patient from Another EMS Crew'?
What should be noted in the narrative when using 'Evaluated and Refused Treatment'?
What should be noted in the narrative when using 'Evaluated and Refused Treatment'?
When would 'Support Services Provided' be recorded?
When would 'Support Services Provided' be recorded?
Which of the following best describes the code 'Transitional Care Refused'?
Which of the following best describes the code 'Transitional Care Refused'?
What must be documented if 'Pre-arrival Activation' is performed?
What must be documented if 'Pre-arrival Activation' is performed?
When selecting 'Position of Patient During Transport', which situation does NOT require documentation?
When selecting 'Position of Patient During Transport', which situation does NOT require documentation?
What does a documented 'Final Patient Acuity' signify?
What does a documented 'Final Patient Acuity' signify?
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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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