St. Johns Fire District Patient Care Reporting

Study Notes

Establishes minimum requirements for patient care reporting and quality review by St. John's Fire District (STJFD).
Aims for standardized processes in patient care reporting and assurance.

ImageTrend "Field" software adopted for documenting patient encounters.
All fields in ePCR must be completed accurately.
ePCRs to be completed within 24 hours of incident notification per DHEC Standard 61-7.
Vital signs must be documented for each encounter, forming part of the patient's medical record.

Narratives are crucial for explaining treatment details and should follow a chronological format.
Key sections include:
- Dispatched To: Describe the initial call and units dispatched.
- Upon Arrival: Overview of the incident scene.
- Chief Complaint: Document the expressed complaints.
- Primary Assessment: Include patient impressions, consciousness, airway, and circulation status.
- Secondary Assessment: Detailed physical examination information such as lung sounds and glucose levels.
- Treatments: Record all treatments and abnormal vital signs.
- Ongoing Assessment: Note patient responses to treatments.
- Notes: Document the patient turnover to the transport agency.

Immediate notification to STJFD Medical Battalion Chief required when an AED is used for data collection and record-keeping.

Patients refusing care must have a STJFD refusal form completed and signed.
ePCR must reflect patient orientation and education related to the refusal.
Refusal forms should be uploaded in PDF format; if scanning is not possible, follow proper envelope procedure to ensure compliance.

Aims to ensure professional and systematic emergency medical care.
Review responsibility lies with the Medical Battalion Chief, command staff, and Medical Director.
Company officers must verify completion of patient care reports.

Level 1 Review: Triggered by significant incidents (e.g., cardiac arrest, airways inserted, patient refusals). Assignments must be processed within 14 days.
Level 2 Review: Triggered by identified infractions beyond documentation errors; handled by Medical Battalion Chief.
Level 3 Review: Conducted by Command Staff upon severe findings from Level 2; may require intervention from the Medical Director.

Accurate reporting impacts patient care and medical records.
Compliance with protocols is essential for quality assurance.
Each level of review escalates if issues are not resolved at a lower level.
Timely completion and meticulous documentation uphold the integrity of the emergency medical services provided.