Patient Care Reports PCR Flashcards

Questions and Answers

What is a Patient Care Report (PCR)?

Prehospital care report, is the legal document used to record all aspects of the care your patient received, from initial dispatch to arrival at the hospital.

Which of the following are functions of a Patient Care Report? (Select all that apply)

Emergency contact list

Continuity of care (correct)

Legal documentation (correct)

Evaluation and continuous quality improvement (correct)

What information is typically collected on a PCR?

Chief complaint, level of consciousness, vital signs, initial assessment, patient demographics.

What are examples of administrative information gathered from a PCR?

Time of incident report, time EMS unit was notified, time EMS unit arrived on scene. Signup and view all the answers

What should be included in a standardized uniform component of a PCR? (Select all that apply)

Nature of the call Signup and view all the answers

Why is documentation important?

Education and research, administrative uses, quality improvement. Signup and view all the answers

What key information should the narrative section of a PCR include?

Time of events, assessment findings, emergency medical care provided, final patient disposition. Signup and view all the answers

What are some methods for writing a narrative report?

Standard precautions, scene safety, number of patients, primary and secondary assessments. Signup and view all the answers

What does the CHART or CHARTE method stand for?

Chief complaint, history and physical examination, assessment, treatment (RX), and transport. Signup and view all the answers

How should refusal of care be documented?

Document the advice given about risks, have the patient sign a refusal form, and witness statements if necessary. Signup and view all the answers

What components should a thorough patient refusal document include?

Complete assessment, patient understanding, discussion of consequences, family discussion, and signatures. Signup and view all the answers

What information should be included in your oral report on a patient?

Patient's name, chief complaint, medical history, treatment response during transport. Signup and view all the answers

Study Notes

Patient Care Reports (PCR)

A Patient Care Report (PCR) is a legal document that records all aspects of prehospital patient care from dispatch to hospital arrival.

Functions of the PCR

Ensures continuity of patient care.
Serves as legal documentation for the services provided.
Fuels education for medical personnel.
Provides administrative information for health records.
Used for essential research purposes.
Facilitates evaluation and ongoing quality improvement.

Information Collected in a PCR

Chief complaint of the patient.
Level of consciousness categorized by the AVPU scale (Alert, Verbal, Pain, Unresponsive).
Vital signs including heart rate, blood pressure, respiration.
Initial assessment results.
Patient demographics, such as age, gender, and ethnicity.

Administrative Information in a PCR

Records incident report time, EMS unit notification time, arrival time on scene, and patient transfer time.
Logs the time of EMS departure from the scene and arrival at a receiving facility.

Uniform Components of a PCR

Patient's name, gender, date of birth, address, and dispatch details.
Chief complaint and location during first contact.
Treatment administered before EMS arrival.
Observations and signs/symptoms noted during the assessment.
Care and treatment provided, vital signs, SAMPLE history, and patient insurance information.
Documented times of calls, dispatch, and transfers of care, along with EMTs' names/designation.

Importance of Documentation

Essential for education and research purposes.
Necessary for administrative record-keeping and legal protection.
Crucial for quality improvement efforts.

Narrative Section of PCR

Should include timeline of events, assessment findings, care provided, patient responses, observations at the scene, and final disposition.
Document refusal of care if applicable.

Writing a Narrative Report

Follow a structured approach: standard precautions, scene safety, number of patients, assessment, vital signs, ABCs (Airway, Breathing, Circulation), patient history, and transfer details.

Documentation Methods

CHART/CHARTE: covers chief complaint, history, assessment, treatment, and transport; CHARTE includes exception notes.
SOAP: subjective data, objective data, assessment, and plan for care.

Documenting Refusal of Care

Complete a PCR even if care is refused; document advice given to the patient about refusal risks.
Secure signatures from witnesses, such as family members or police, if the patient refuses to sign.

Components of Patient Refusal Documentation

Detailed assessment and evidence of informed decision-making.
Discussion of care recommendations and potential consequences of refusal.
Attempts to encourage acceptance of care by family or friends.
Document any consultations with medical direction and alternative suggestions offered.
Signatures from witnesses to substantiate refusal claims.

Oral Report Components

Include patient name, chief complaint, illness details, treatment responses, vital signs during transport, and any pertinent medical history or medications.
Report significant changes in the patient's condition during transit.

Description

Explore key terms and functions of Patient Care Reports (PCR) with these flashcards. This quiz covers essential definitions and the importance of PCR in prehospital care. Perfect for healthcare professionals and students alike!