NORTH COAST EMERGENCY MEDICAL SERVICES Policy # 2402
POLICIES AND PROCEDURES
Subject: Medical Control
Prehospital Care Report (PCR)
I. Authority and Reference (incorporated herein by reference)
A. Title 22, California Code of Regulations.
B. Health and Safety Code.
C. North Coast Emergency Medical Services Policies and Procedures.
II. Purpose
To define the process for documenting patient care and for completion and distribution of the Prehospital Care Report (PCR) form.
III. Procedure
A. A North Coast EMS (NCEMS) approved PCR will be completed for every patient, including cases in which the patient is not transported. Exception: Completion of a PCR is not required for routine, non-emergency facility-to-facility transfers that require only basic (BLS) care. If a transfer involves the use or maintenance of any advanced (ALS/LALS) procedure, a PCR is required.
B. The PCR will be filled out completely, including all required elements as defined in the NCEMS "Prehospital Care Reporting & Database System: Guidelines for PCR Completion".
C. Each ALS/LALS Service Provider Agency is responsible for training EMT employees in the initiation, completion, and distribution of the PCR. The base hospital Prehospital Care Nurse Coordinator (PCNC) will provide assistance and support in orientation of new personnel to the Prehospital Care Reporting and Database System (PCR-DS) used in PCR completion.
D. The PCR must be completed immediately upon delivery of the patient to the receiving facility. A delay in submitting the report is permissible if extenuating circumstances exist, such as another call/assignment occurring which would preclude the ability to complete the PCR, or a non-transporting EMT transferring patient care to another EMT and not accompanying the patient to the hospital. In these circumstances only, delivery of the completed PCR may be delayed up to 24 hours.
NORTH COAST EMERGENCY MEDICAL SERVICES Policy #2402
POLICIES AND PROCEDURES Page 2 of 2
Subject: Medical Control
Prehospital Care Report (PCR)
E. EMT's must utilize the Prehospital Care Reporting and Database System to generate a PCR upon patient delivery to a regional hospital. The PCR must be completed in accordance with the "NCEMS Prehospital Care Reporting & Database System: Guidelines for PCR Completion". Exceptions to the use of the automated data system are as follows:
1. The PCR-DS is out of service.
2. The prehospital care personnel are dispatched to another call/assignment.
F. Under extenuating circumstances when a PCR is not completed at the time of patient delivery, the prehospital care personnel must:
1. Leave relevant patient information with the receiving hospital R.N. or M.D. ensuring that information needed for continuing care of the patient has been provided.
2. Complete the PCR on the PCR-DS and deliver a copy to the receiving hospital within 24 hours.
3. Notify the base hospital PCNC of the delay utilizing the PCR-DS Notification Form.
G. Prehospital care personnel without access to the PCR-DS may utilize the NCEMS approved (handwritten) PCR according to the specifications in the "NCEMS Prehospital Care Reporting & Database System: Guidelines for PCR Completion". In addition, the base hospital PCNC must be notified in writing utilizing the PCR-DS Notification Form why the handwritten form was used.
H. The PCR must indicate if radio delay and/or radio failure protocols were utilized. (Follow procedures outlined in policy #2404).
I. Review of the PCR will follow the medical control procedure.
Cross Reference Policy #s: 2102, 2103, 2109, 2404
Approved:____________________________________Date_________________
Approved As To Form:__________________________Date:_________________