By: Eric Lee, Training Officer, 2016-2017
Each time EMS is called to a scene, the EMT on call may be seen writing on a white document. This document is known as a Pre-hospital Care Report (PCR) and is completed for each call VCEMS responds to. The main purpose of a PCR is to record the treatment and care provided by the VCEMS and to ensure that the necessary information is passed on to healthcare providers for the continuation of care.
While on scene, general information such as the patient’s name, age, vital signs, allergies, medications, past medical history, and symptoms are recorded. Typically, at least two sets of vitals will be obtained during a call to be able to accurately assess the patient’s condition during the call. In cases where the patient is transported to the hospital for further care, this information is key in order to provide the proper treatment once care of the patient is transferred from one provider to another. Specifically, for VCEMS, the ambulance crew that arrives to transport the patient is given a copy of the PCR so that they have the necessary information to treat the patient. After the call, a narrative is written up detailing the event of the call, including the assessment and findings the EMTs may have come upon.
Like any medical record, a PCR will only be read or seen by those who are directly involved in patient care. The importance of patient privacy both during and after a call are of utmost importance to VCEMS. This includes allowing only those who are directly involved in the patient’s care to have access to the PCR pertaining to a particular call. A copy of the PCR is given to Baldwin Health Services for a follow up appointment to be certain that the complete treatment is provided for a patient. All EMS agencies, including VCEMS, are not legally permitted to disclose any information regarding the patient to anyone not directly involved in the care of the patient. For example, if an ambulance is called to transport the patient to the hospital, EMS is allowed to update and explain the current situation to the ambulance crew since the new crew will take over the care of the patient; however, if security or police personnel are at the scene and ask EMS for any information, even as general as the patient’s date of birth, EMS will not disclose any information. The patient is of course allowed to disclose any information he/she may choose to security or police personnel.
PCRs help facilitate the effective care of patients from one provider to another. It is critical that the PCR is completed accurately, as it serves not only as a method to transfer important information to other healthcare providers, but also as a legal document detailing the care EMS provided. The importance of patient confidentiality cannot be stressed enough to maintain the trust that must exist between EMS and its patients that allows VCEMS to effectively treat patients.