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What is a Patient Care Report (PCR)?
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)
Which of the following are functions of a Patient Care Report? (Select all that apply)
What information is typically collected on a PCR?
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?
What are examples of administrative information gathered from a PCR?
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What should be included in a standardized uniform component of a PCR? (Select all that apply)
What should be included in a standardized uniform component of a PCR? (Select all that apply)
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Why is documentation important?
Why is documentation important?
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What key information should the narrative section of a PCR include?
What key information should the narrative section of a PCR include?
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What are some methods for writing a narrative report?
What are some methods for writing a narrative report?
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What does the CHART or CHARTE method stand for?
What does the CHART or CHARTE method stand for?
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How should refusal of care be documented?
How should refusal of care be documented?
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What components should a thorough patient refusal document include?
What components should a thorough patient refusal document include?
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What information should be included in your oral report on a patient?
What information should be included in your oral report on a patient?
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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.
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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!
