St. Johns Fire District Patient Care Reporting

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.