Documentation=
of
the Patient Care Report
Poli=
cy:
An EMS patient care report will be complete accurately to
reflect the patient assessment, patient care and interactions between EMS and the patient, for each patient contact, which
results in some assessment component.
Purp=
ose:
The
purpose of this policy is to document:
- The
total patient care provided including:
- System
data regarding the EMS systems res=
ponse
- Dispatch
information regarding the dispatch complaint and the EMD card number<=
o:p>
- Care
provided prior to EMS arrival=
- Exam
of the patient as required by each specific complaint based protocol<=
o:p>
- Past
medical history, medications, allergies, living will / DNR, and perso=
nal
MD
- All
times related to the event
- All
procedures performed and their associated time
- All
medications administered and their associated time<=
/li>
- Disposition
and / or transport information
- All
communications with medical control
- Signatures
of technicians providing care
- Signature
of treatment authorized (if any deviation from protocol)
- Signature
of receiving individual assuming patient care at the medical facility=
- Reason
for inability to complete or document any above item=
Proc=
edure:
1. The patient care report shoul=
d be
completed as soon as possible after the patient encounter and must be compl=
eted
within 12 hours of the encounter (unless approved by the Supervisor).<=
/o:p>
2. All patient interactions are =
to be
recorded utilizing the patient care report electronic form and a signature
sheet. If the patient refuses=
any
portion of the evaluation, treatment, or transport a disposition form must =
be
completed.
3. The patient care report must
include the information listed above.
4. A copy of the completed patie=
nt
care report should be faxed to the receiving facility.
5. The original electronic patie=
nt
care report will be stored by the Catawba
County Information
Technology Center. The original signature sheet=
s will
be stored by the Catawba County Emergency Servcies Department.=