What is a CDRFC of a PCR. I wonder how many EMT and Paramedics out there can guess? Let's see did you get it right. My topic for this post is the confidentiality, allowed distribution of information, the documentation of refusal of treatment, falsification of a report, and correction of errors on the Prehospital Care Report.
- PCR is confidential
- Do not show form or discuss info with unauthorized personell
- Remember HIPAA
- Follow state and local protocols
- Distribute to heal care provider, police, third party billing, and court if there is a legal subpoena
Refusal of treatment
- Perform as much assessment as possible
- Make sure patient is rational and not suicidal
- Make one last effort of persuation
- Inform patient of why care is needed
- Discuss possible consequences
- Confirm that patient understands
- Discuss situation with medical directive
- Have patient sign refusal of treatment, family member, Police Officer or a bystandard
- Suggest alternative ways to getting to care.
- If its not done, don't write it down
- If you don't write it down its not done.
I think falsification is clear enough. If you didn't do something, don't write it down to cover your behind on the clock. If you did do something, make sure that you write it down.
Correction of errors
Never delete or erase something. Simply put a line through it and continue with the right information on your report.