Questions and Answers
What is the effective date of the St. John's Fire District Patient Care Reporting & Quality Review guideline?
Which software has been approved and adopted by medical control for ePCR?
What is the maximum time allowed to complete an ePCR following incident notification?
Which organization's standard must ePCRs comply with for completion within twenty-four hours?
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What is the purpose of the ePCR narrative?
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What format should be used for all ePCR narratives?
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What should the 'Dispatched To' section of the ePCR narrative include?
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What should the 'Upon Arrival' section of the ePCR narrative describe?
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Who approved the Patient Care Reporting & Quality Review guideline?
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What is a requirement for all ePCRs regarding vital signs?
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Who assigns Level 1 reviews?
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What is the primary focus of a Level 1 review?
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What triggers the need for a Level 2 review?
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Who conducts Level 2 reviews?
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What happens if a Level 2 review cannot be resolved?
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What documentation is sent with the request for a Level 3 review?
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Who conducts Level 3 reviews?
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Within how many days must a Level 1 review be completed?
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Who may advise the member of the outcome of a Level 2 review?
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Who provides the final decision and required action to the member being reviewed at Level 3?
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What action is taken if a patient refuses care or transport?
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What is the required format for uploading the signed refusal form into the ePCR?
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Who is responsible for initiating a Level 1 review?
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Which of the following incidents does NOT require a Level 1 review?
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Where should the original signed refusal form be delivered if it cannot be scanned and uploaded?
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What must the EMT complete after selecting 'refusal' within the Image Trend NEMSIS 3.5 system?
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Who is responsible for ensuring that all ePCRs assigned to their personnel are complete and locked?
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What is the purpose of the medical quality improvement program at STJFD?
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What must be done if the refusal form cannot be scanned and uploaded into the ePCR?
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Who must scan and upload the signed refusal form if it was not done by the report writer?
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What should be documented under the 'Chief Complaint' section?
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What does the primary assessment include?
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What should be documented as part of the secondary assessment?
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Which information is included in the 'Notes' section?
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In which section should all treatments provided to the patient be documented?
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When should the Medical Battalion Chief be notified?
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What should be confirmed to verify airway placement?
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What is required if a patient with an injury refuses treatment?
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What considerations should be documented if capnography is used?
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What should be included in the ongoing assessment?
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Study Notes
Patient Care Reporting
- Electronic patient care reporting (ePCR) software is used to document all patient encounters and treatment.
- ImageTrend "Field" software is the approved ePCR software for the St. Johns Fire District (STJFD).
- All required fields in the reporting software must be accurately completed.
- ePCRs must be completed within 24 hours of the incident notification in compliance with the Department of Health and Environmental Control (DHEC) Standard 61-7.
ePCR Narrative
- The narrative should explain and document treatment information on a patient.
- Narratives should include observations, interventions, assessment of the patient, and other pertinent information.
- The chronological format is the standard format for all narratives.
- The format includes:
- Dispatched To: a brief description of the initial call for service.
- Upon Arrival: a description of the incident scene.
- Chief Complaint: the patient's expressed chief complaint and secondary complaint(s) if applicable.
- Primary Assessment: first impression, patient's level of consciousness, airway, breathing, circulation, history of present illnesses, past medical history, and life-threatening conditions.
- Secondary/Focused Assessment: detailed physical exam or focused assessment, pertinent negatives, lung sounds, and blood glucose level.
- Treatments: all treatments provided to the patient.
- Ongoing Assessment: the patient's response to treatments, medications, or additional assessments.
- Notes: description of patient turnover to the transporting EMS agency.
Additional Required Information in the Narrative
- Airway placement confirmation by checking chest rise and lung sounds.
- Consideration for capnography documentation if a device was used or present.
- Documentation of patient's refusal of treatment, including completion of a medical treatment refusal form.
Notifications
- Notification to the STJFD Medical Battalion Chief whenever an automatic external defibrillator (AED) is used.
Patient Refusals
- When a patient chooses to refuse care or transport, the EMT ensures that the STJFD patient refusal form is completed and signed by the patient.
- The ePCR report writer documents the patient's orientation and education of refusal.
- The signed refusal form is uploaded into the ePCR in PDF format.
Medical Quality Assurance and Improvement
- The quality improvement program ensures that emergency medical care is rendered in a professional and systematic format.
- The Medical Battalion Chief, with coordinated efforts from the command staff and Medical Director, provides a thorough review of emergency medical incidents.
- Company officers are responsible for ensuring patient care reports are completed by personnel assigned to them.
- The Medical Battalion Chief initiates a Level 1 review on all incidents that mandate review.
Level 1 Review Activators
- Cardiac Arrest (working or DOA)
- Insertion of any airway adjuncts
- Citizen complaints
- Medication Administration (oxygen administration is not included)
- Patient Refusals obtained by STJFD EMTs
- Other circumstances, as determined by the Fire Chief, Command Staff, Medical Battalion Chief, or Medical Director.
Formal Quality Improvement
- The STJFD utilizes a process involving three levels of review in its Quality Improvement Program.
- Level 1 reviews are performed on reports that warrant a review based on the identified priorities of the Fire Chief, Medical Battalion Chief, or Medical Director.
- Level 2 reviews are conducted when the EMT or Paramedic conducting a Level 1 review identifies infractions or deviations from protocols.
- Level 3 reviews are conducted when further action is warranted based on the findings of the Level 2 review.
- Level 3 reviews are conducted by members of Command Staff under the consultation of the Medical Director, as deemed necessary.
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Description
This quiz covers the standard operating guidelines for patient care reporting and quality review in the St. Johns Fire District. It outlines the minimum requirements and objectives for effective patient care reporting and quality assurance review.
