Policy 12 — Documentation of PCR

When must documentation of a patient encounter be completed?

Immediately following the encounter

What legal significance does a completed PCR carry?

It becomes a permanent record of the encounter and will serve as a legal document in the event of litigation

What does the acronym SAMPLE stand for in patient documentation?

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

What seven ambulance time points should be documented, when applicable?

Dispatched Time, Ambulance Enroute Time, Ambulance On-Scene Time, Depart Location Time, Arrive Hospital Time, Ambulance In Service Time, Ambulance Stage Time, and Patient Encounter Time

What location details must be documented for both the pickup and destination?

The complete address and zip code for each

At what two points must a detailed patient examination be documented?

Upon contact and at destination

How must GCS be documented in the PCR?

Categorized

When is an APGAR score included in documentation?

When applicable, for childbirth

Whose names and signatures must be included in the PCR?

Full crew names, with an authorizing signature

Who is responsible for ensuring HIPAA information has been given to the patient?

In-charge medics

What effort must be made regarding the patient's signature for HIPAA acknowledgment?

A good faith effort must be made to obtain the patient's signature acknowledging receipt of the information

What additional information must be documented if the patient is a minor or has delegated healthcare decision-making to another person?

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

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

Their signature, or the responsible party's signature, on an approved Release from Liability form