ePCR PRF v1.pdf

ePCR Electronic Patient Care Record PRF (Patient Report Form) Paper version Have you completed your ePCR eLearning? London Ambulance Service NHS Trust 2  Paper PRF (LA4) Complete all boxes White copy given to HCP on handover Handed in with LA1 at end of the shift A medic...

ePCR Electronic Patient Care Record PRF (Patient Report Form) Paper version Have you completed your ePCR eLearning? London Ambulance Service NHS Trust 2  Paper PRF (LA4) Complete all boxes White copy given to HCP on handover Handed in with LA1 at end of the shift A medical and legal document London Ambulance Service NHS Trust 3  Medical model documentation History Assessment findings HPC CVS PMH RS PSH GI/ GU FHX Neu SHX MSS DHx IMP Birth Hx Plan London Ambulance Service NHS Trust  Systematic (medical model) Legible 1 neat line through errors +ve and –ve findings equally important A patient is only ‘well’ if you assess and document your findings fully London Ambulance Service NHS Trust  Use accepted abbreviations BS: Breath sounds or bowel sounds? Abbreviations Don’t use ‘amusing’ abbreviations on your PRF London Ambulance Service NHS Trust The tutor will facilitate your access to the TRAINING app This is shown on the right here London Ambulance Service NHS Trust 7  Do not use pre-written information to ‘save time’ Do not use ‘cut and paste’ Free text These do not represent a true account of the patient encounter Each ePCR should be contemporaneous (Created during the patient consultation London Ambulance Service NHS Trust 8  Create a case and look at the tabs on the left Explore the You cannot ‘delete’ a case by accident ePCR app You cannot do anything ‘wrong’ Be mindful of using ‘amusing’ data (The training cases are logged) London Ambulance Service NHS Trust 9  Personal Demographic Service (PDS) On the ‘Patient Details’ tab Populate the name, DoB and postcode [PDS trace] DNACPR Care planning Patient information Then confirm your selection London Ambulance Service NHS Trust 10 London Ambulance Service NHS Trust 11 Scenario 1 The tutor/s will now facilitate a medical scenario The crew attending and those watching should complete the ePCR as the scenario runs There will be time after the scenario to ask further questions to help complete the ePCR London Ambulance Service NHS Trust 12 Scenario 2 The tutor/s will now facilitate a trauma scenario The crew attending and those watching should complete the ePCR as the scenario runs There will be time after the scenario to ask further questions to help complete the ePCR London Ambulance Service NHS Trust 13  CPIs Supports audit Highlights areas for improvement “Are patients given the best care?” Includes Cardiac arrest Sepsis Random sample Not-conveyed MH Sickle cell London Ambulance Service NHS Trust 14  Any questions? London Ambulance Service NHS Trust 15