Policy 12–PCR Documentation

When must PCR documentation be completed?

Immediately following each patient encounter.

Why is careful PCR documentation so important?

It becomes a permanent legal record of the encounter and may serve as a legal document in litigation.

What patient identifying information is required on the PCR?

Full name, complete address, and contact telephone number.

What ambulance times must be documented?

Dispatched time, ambulance enroute time, ambulance on-scene time, depart location time, arrive hospital time, ambulance in-service time, stage time (if applicable), and patient encounter time (if applicable).

What location information must be documented?

The patient pickup location and destination location/facility, each with complete address and zip code.

What does SAMPLE stand for in patient history documentation?

Signs & Symptoms, Allergies, Medications, Previous history, Last meal, and Events leading up to the acute event.

What clinical documentation is required besides SAMPLE?

Detailed patient examination upon contact and at destination, chronological event/treatment sequence, GCS (categorized), and APGAR when applicable (childbirth).

What crew and equipment information must be recorded?

Full crew names with authorizing signatures, ambulance/unit identifier, and protective equipment/other state reporting information.

What must in-charge medics ensure regarding HIPAA?

That HIPAA information has been given to the patient, with a good-faith effort to obtain the patient's signature acknowledging receipt.

What extra documentation is needed if the patient is a minor or has delegated healthcare decisions to someone else?

The full name and contact information of the individual making healthcare decisions.

What must be obtained if a patient refuses transport to the hospital?

The patient's (or responsible party's) signature on an approved Release from Liability form.