St. Johns Fire District Patient Care Reporting

Questions and Answers

What is the purpose of the Patient Care Reporting & Quality Review policy?

To establish the minimum requirements for patient care reporting and quality review by the St. John's Fire District.

What ePCR software is approved for use by the St. John's Fire District?

The ImageTrend 'Field' software is the approved ePCR software.

Within what timeframe must ePCRs be completed after an incident notification?

ePCRs must be completed within twenty-four hours.

What should the ePCR narrative include?

The narrative should include observations, interventions, assessment of the patient, and other pertinent information. Signup and view all the answers

Why is accurate information critical in patient care reporting?

Accurate information is imperative because it becomes part of the patient's medical record. Signup and view all the answers

What should be documented as the chief complaint during patient care reporting?

The patient's expressed chief complaint and any secondary complaints if applicable. Signup and view all the answers

What does the primary assessment include?

It includes the first impression, patient's level of consciousness, airway, breathing, circulation, history of present illnesses, past medical history, and life-threatening conditions. Signup and view all the answers

What types of information should be included in the ongoing assessment?

The patient's response to treatments, medications, or additional assessments performed. Signup and view all the answers

What must an EMT or Paramedic include during the patient turnover to the transporting EMS agency?

They should include a description of the patient turnover along with ALS/BLS transport unit number or other identification. Signup and view all the answers

How can airway placement be confirmed according to the guidelines?

Airway placement shall be confirmed by checking chest rise and lung sounds. Signup and view all the answers

Study Notes

Patient Care Reporting & Quality Review Overview

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.

Electronic Patient Care Reporting (ePCR)

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.

ePCR Narrative Requirements

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.

Notifications and AED Use

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

Patient Refusals

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.

Medical Quality Assurance Process

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.

Levels of Review for Quality Improvement

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.

Key Points to Remember

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.

Description

This quiz covers the standard operating guidelines for patient care reporting and quality review established by the St. Johns Fire District. It outlines the minimum requirements necessary for effective patient care documentation. Prepare to test your understanding of the essential policies and procedures as approved by Chief Ryan Kunitzer.