# Patient Care Reports



## ffemt8978 (Jul 9, 2004)

I would like to know how every one else completes their patient care reports.


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## SafetyPro2 (Jul 9, 2004)

The County has a standard report form that we have to use. It's a 5-sheet carbonless form, and we have to leave one sheet with the ER when we hand off the patient. Technically, no additions can be made to the form once we hand off the copy. We have been adding the dispatch time info after we hand off that copy, but we're trying to make sure and even complete that at the hospital now. Therefore, pen and paper's really the only practical way for us.


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## ffemt8978 (Jul 9, 2004)

We actually have a state wide form, called the Medical Incident Report.  Not all agencies use this form, but all the information on it must be in their form and it must be approved by their medical control and the state.  Ours is a three part carbonless, and we have to leave one part with the hospital.

I've actually entered all of the information from our report into my PDA and developed into a database.  I then posted the database on the web for everyone to download, free of charge.  One of our state regional EMS councils is looking at the program to possibly implement in their region.   B)  B)


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## ResTech (Jul 9, 2004)

Pennsylvania uses electronic data collection. All PCR's are completed by computer software approved by the department of health. We print a hard copy of the report and then our Chief electronically file's the data every month with the regional EMS council.


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## rescuecpt (Jul 9, 2004)

NY State uses a 3-sheet carbonless form.  The white top sheet stays with the agency, and the yellow and pink sheets are left with the hospital.  The hospital keeps the yellow one for the patient records, and the pink sheet is sent to the state for research/records purposes.


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## MMiz (Jul 9, 2004)

We use a multi-sheet carbonless form.  It's specific to our county.  The county then requires us to fill out a bubble sheet (scantron) with the same information.  Scantrons always seem to mess me up.


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## TTLWHKR (Jul 24, 2004)

Used to be in PA we had different forms for each EMS region; then there was an option have having a state wide form that was a white-pink-yellow carbonless copy. Then about 7-8 years ago we switched to data collection software that covered all aspects of the PCR. My service still uses the white portion of the carbonless PCR's as a hard copy and simply b/c this is easier to report on in the field, and the ER likes to have a copy, also this way if we don't have time to enter them into the "Code 3 Software" upon completion of the call, we can lock them in our mail boxes which we incorporated after all this hipaa stuff began.


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## PArescueEMT (Dec 24, 2004)

> _Originally posted by ResTech_@Jul 9 2004, 02:07 AM
> * Pennsylvania uses electronic data collection. All PCR's are completed by computer software approved by the department of health. We print a hard copy of the report and then our Chief electronically file's the data every month with the regional EMS council. *


 Not everywhere are we papreless, I am still recording with a pen and paper.


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## coloradoemt (Dec 31, 2004)

I recently changed from a system that was all computerized to one that is planning it in the near future. Had to go back to school on the paperwork side....


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## Jon (Dec 31, 2004)

> _Originally posted by coloradoemt_@Dec 31 2004, 04:03 PM
> * I recently changed from a system that was all computerized to one that is planning it in the near future. Had to go back to school on the paperwork side.... *


 Yup. It sucks, don't it.


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## coloradoemt (Dec 31, 2004)

> _Originally posted by MedicStudentJon_@Dec 31 2004, 03:05 PM
> *
> Yup. It sucks, don't it. *


 Sure does... About the time my hand quits cramping up from all the writing, I will get to go back to keyboard entry again.


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## shorthairedpunk (Feb 12, 2005)

we have a war brewing over whether we need a nurses signature on out pcrs. other agencies in the area dont get them and the state doesnt care. what do you guys think?


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## CodeSurfer (Feb 22, 2005)

I rode along with San Diego Fire and the medics used a PDA to record everything and when we got to the ED they used an IR port to send the data to the printer.  It seems like a really good system, although it can take a long time to type everything out with the little stylus on the screen.


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## rescuecpt (Feb 22, 2005)

> _Originally posted by shorthairedpunk_@Feb 12 2005, 02:27 PM
> * we have a war brewing over whether we need a nurses signature on out pcrs. other agencies in the area dont get them and the state doesnt care. what do you guys think? *


 We're required in NYS.  We get in trouble from the County and/or DOH for not having them.  It shows the completion of your care - transfer of care to a higher authority.  Without it, the state assumes you left the pt on the side of the road...


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## Summit (Feb 22, 2005)

Can't... wait... for... COMPUTERS!


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## emtchicky156 (Feb 23, 2005)

Here in wi we have to get a signature too. Sometimes it's  a pain in the *** to get when they are busy, but ya gotta do what ya gotta do.


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## Jon (Feb 24, 2005)

Philly uses "lifenet EMT" - Zoll's System - the ED staff just sign the screen with the syulus, same as the pt.


Jon


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## killerkeev (Mar 6, 2005)

I am from Ohio, central, and we do our reports on computers.  We actually have a handheld unit that is a little bigger than you hand.  We require signatures from the nurses as a way to protect ourselves from people saying we didn't give report.  It also acts as a way to state that we Passed on care to an equal or higher level of care.  We then print a copy out and leave it for the hospital medical records and go back and upload the reports into the database.  We are hopefully going to be going wireless here in the near future.


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## Phridae (Mar 6, 2005)

Wisconsin has its own run report. 3 layers. White, yellow, pink. We need a sig. from an RN and the pink copy stays at the ED. We take the yellow and white home.
We just purchased a computer system, and theres heavy talk of everything going to computers this year. Then again, there was heavy talk of getting a new moniter, last summer.


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## SCEMT-B (Mar 7, 2005)

SC uses a 3-part carbonless form, but our company has switched to computers so now we're printing them.


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## Jon (Mar 8, 2005)

> _Originally posted by SCEMT-B_@Mar 7 2005, 10:34 PM
> * SC uses a 3-part carbonless form, but our company has switched to computers so now we're printing them. *


 are you printing on the forms, or genertating 2 or 3 single copies? Are they the same as the state form, or set up differently?

Jon


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## TKO (Mar 23, 2005)

In Sask. there are a few different ways. Each service to their own I guess. All places I have been , are pen and the PCR form. The bigger city has little laptops which you fill out on then print them out at the hospital.


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## EMICT1 (Mar 24, 2005)

Here in KS every service is different.  The Private service I work for still uses a carbonless paper report.  While,  Sedgwick county the primary 911 provider for this area does theirs on Computer and have been experementing with the MEDUSA tablet system.  All of the techs I have talked to hate the tablets. They complain of reports that have been completed and just vanish into some electronic abbys.  I personally like the paper.  I always know where it is and dont have to work about technical difficulties.


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## BloodNGlory02 (Mar 24, 2005)

> *Wisconsin has its own run report. 3 layers. White, yellow, pink. We need a sig. from an RN and the pink copy stays at the ED. We take the yellow and white home.
> We just purchased a computer system, and theres heavy talk of everything going to computers this year. Then again, there was heavy talk of getting a new moniter, last summer.*



Thats not true of the whole state. I know of several depts who dont use the state report. They make their own based on the state report. We DONT need anyone to sign ours- to us thats pointless- we dont sign the pt's hospital chart so why should the hospital sign ours? We leave the white with the hospital since thats the main file. I doubt any small community around me is using computers anytime soon. Estimated start up cost was around $150,000. I dont see the computer reports being any quicker or easier. There are some people who cant type to save their life. Are they ever going to want to "write the narrative" if it takes them 25 minutes to type it out? of course not. someone else is always going to be doing it to get it done faster. I dont like the idea of computer reports at all.


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## Chimpie (Mar 24, 2005)

One of my past security departments did all of their reports, including medical reports, by hand.  The next day our admin asst typed them all in.


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## rescuecpt (Mar 24, 2005)

> _Originally posted by BloodNGlory02_@Mar 24 2005, 12:43 AM
> * We DONT need anyone to sign ours- to us thats pointless- we dont sign the pt's hospital chart so why should the hospital sign ours? *


 Here the point is that it proves we transferred care properly.  Otherwise, in theory, we could just dump someone at the door and walk away and say that we delivered them to the hospital.  On our PCRs it signifies the hospital's acceptance of our transfer of care and ends our obligation to care for the patient.


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## SCEMT-B (Mar 27, 2005)

> _Originally posted by Summit_@Feb 22 2005, 03:02 PM
> * Can't... wait... for... COMPUTERS! *


Better hope your dept/company gets the good ones. Ours didn't  <_<  and our computers go down prolly once a week and then we have to use paper reports til they're fixed 2 weeks later  :blink:


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## Ray1129 (Apr 8, 2005)

MD utilizes what they call EMAIS.  It's all on the web.  We access it with our provider numbers and passwords and when we're done, we print out what we just did and send copies to everyone who needs them.  Then the call is logged under your name so that if you ever need to go back to it for some odd reason, it's there to look at.  Pain is if the internet is down or if the site crashes....

-Ray


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## ma2va92 (Apr 8, 2005)

What program are out there... for the VOL...... the city near us has great laptops.. heck then don't need to call dispatch if they don't want to... 
one of the Vol RS near us is screaming that there somputer base pre hospital takes so long .. and is not very friendly.... I havn't seen much on the web.. but then again I may be looking in the wrong place... we are small.. 2 medic truck .. third coming soon... we run about 850 900 calls per year and the search is on.. as we will need to go to computer reports in the coming year....


any help  gets a big TY


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## ffemt8978 (Apr 8, 2005)

GVRS672,

You may want to check with your state EMS office and see what they recommend.  Sometimes they have specific requirements for the programs.  Also check with the hospital you transport to and see if they are set up to receive computer reports.

If all else fails, you could probably write a program in Microsoft Access or something similar that would meet all of your needs.


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## Jon (Apr 8, 2005)

In PA, there is a group in the Pittsburg area that puts out "EMMA" and that meets the state regs. Also, I've heard of "Code 3" as another program.

In my county, everyone does computer reports in the station after returing to quarters. Some squads are talking of running EMMA on a palmtop PC or MDC, as we upgrade units, as the county MDT's are getting old and breaking, with no replacement in sight.

Hope that helps a little.


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## TTLWHKR (Apr 8, 2005)

New HIPAA regulations state that we will no longer be able to use our Code 3 Software to send PCRs to our regional office by way of the internet. We however may place them into the C3S and save that month to a disc, or a series of discs and mail them to the directors.  :angry:  I'm really starting to 'strongly dislike' HIPAA.


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## rescuecpt (Apr 8, 2005)

> _Originally posted by TTLWHKR_@Apr 8 2005, 01:49 PM
> * New HIPAA regulations state that we will no longer be able to use our Code 3 Software to send PCRs to our regional office by way of the internet. We however may place them into the C3S and save that month to a disc, or a series of discs and mail them to the directors.  :angry:  I'm really starting to 'strongly dislike' HIPAA. *


 Just "starting"???


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## Jon (Apr 8, 2005)

> _Originally posted by TTLWHKR_@Apr 8 2005, 01:49 PM
> * New HIPAA regulations state that we will no longer be able to use our Code 3 Software to send PCRs to our regional office by way of the internet. We however may place them into the C3S and save that month to a disc, or a series of discs and mail them to the directors.  :angry:  I'm really starting to 'strongly dislike' HIPAA. *


 At my one squad - 1000 or so runs a year, we download EMMA to floppy and mail to county on about a monthly basis.

Jon


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## TTLWHKR (Apr 9, 2005)

> _Originally posted by rescuecpt+Apr 8 2005, 01:58 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (rescuecpt @ Apr 8 2005, 01:58 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-TTLWHKR_@Apr 8 2005, 01:49 PM
> * New HIPAA regulations state that we will no longer be able to use our Code 3 Software to send PCRs to our regional office by way of the internet. We however may place them into the C3S and save that month to a disc, or a series of discs and mail them to the directors. :angry: I'm really starting to 'strongly dislike' HIPAA. *


Just "starting"??? [/b][/quote]
 I watched the HIPAA Video for .5 CEUs, and thats what the video said. So I called the regional lady (she's a real bit....um nevermind) and she confirmed.


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## rescuecpt (Apr 9, 2005)

> _Originally posted by TTLWHKR+Apr 8 2005, 11:01 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (TTLWHKR @ Apr 8 2005, 11:01 PM)</td></tr><tr><td id='QUOTE'>
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I watched the HIPAA Video for .5 CEUs, and thats what the video said. So I called the regional lady (she's a real bit....um nevermind) and she confirmed. [/b][/quote]
 I meant you're just starting to dislike HIPPA?  I started disliking it from day... 2.


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## TTLWHKR (Apr 9, 2005)

> _Originally posted by rescuecpt+Apr 9 2005, 11:14 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (rescuecpt @ Apr 9 2005, 11:14 AM)</td></tr><tr><td id='QUOTE'>
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I meant you're just starting to dislike HIPPA?  I started disliking it from day... 2. [/b][/quote]
I started to dislike it when we had to go back to having patients sign forms again. HIPAA comes in a four page booklet for them to sign, whereas it now requires seperate privacy policies. These differ with types of services. Theres a catch. We have three ambulance in the station. One is Paid ALS, One is Municipal BLS, One is Fire/BLS. Each is owned by different people, each has it's own policy; and they are all together. So they have to sign the HIPAA Act, the Privacy Act, the Billing form (has to be signed by them while in the ambulance, can't be handled by the hospital anymore - even though they do our billing - all b/c of privacy) and they have to sign another form saying that we performed up to their expectations (total bull $hit), it's for QA. Then we have to get a form signed for equipment used, that is signed by the ER unit Clerk, so we can bill the patient for disposable supplies.  :blink: Plus we have to take HIPAA and Privacy Policy Update Classes every six months.


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## possum (Apr 12, 2005)

In Virginia we still do the paper work my hand. Then we have to put the PPCR call sheet in to the computer. Then we email to the state office.

 possum 

  375


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## MedicPrincess (Apr 12, 2005)

The next county over uses laptops, then at the end of the shift they are downloaded and printed.  The providers in my county do them by hand.


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## TTLWHKR (Apr 12, 2005)

I only need a few more posts to make 300. Don't mind me, I'll just do it from the corner.


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