Thursday, April 21, 2016

The different parts of a Prehospital Care Report

Are you ready for another day of Emergency Medical Technician classes? In the last refresher and training post, I talked about the different parts of a Prehospital Care Report. The report is not going to have five empty spaces. The Department of Transportation and other facilities are going to need to know pertinent information from those in contact with the patient. 

If you remember there are five different areas on the Prehospital Care Report. They are Patient Information, Administrative Information, Administrative, Patient Demographics, Vital Signs, and Patient Chief Complaint in their own words. What does an EMT have to include in each section?

Patient Information

  • Chief complaint
  • Level of responsiveness
  • Blood pressure for patients over 3 years old
  • Skin Perfusion (Capillary refill) for patients less than 6 years old
  • Skin color, temperature, and condition of skin
  • Pulse rate
  • Respiratory rate and effort of breathing


Administrative Information

  • Time the incident was reported
  • Time the unit was notified
  • Time of arrival at the patient
  • Time the unit left the scene
  • Time the unit arrived at its destination
  • Time of transfer care.


Administrative

  • EMS Unit Number
  • Names of crew members and level of certification
  • Address of patient
Patient Demographics
  • Legal name, age, sex, race, and birth date
  • Home address
  • Insurance or billing information
  • Care given before EMT arrived
Vital Signs
  • Two complete sets of vital signs
  • Record of what position the patient was in

Patient Narrative
  • Patients chief complaint in patients own words
  • Patient history
  • Objective and subjective information
  • Symptoms based on chief complaint
In the next post I plan to include all the abbreviations that an EMT or Paramedic has to deal with. In the future I will also be discussing Objective information, Subjective information, Confidentiality of the PCR, distribution of information, documenting refusal of treatment, falsification of the PCR, and correction of errors on the Prehospital Care Report. 


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