Patient Care Reports

[ffemt8978]

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

 

[SafetyPro2]

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.

 

[ffemt8978]

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)

 

[ResTech]

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.

 

[rescuecpt]

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.

 

[MMiz]

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.

 

[TTLWHKR]

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.

 

[PArescueEMT]

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.

 

[coloradoemt]

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....

 

[Jon]

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.

 

[coloradoemt]

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.

 

[shorthairedpunk]

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?

 

[CodeSurfer]

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.

 

[rescuecpt]

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...

 

[Summit]

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

 

[emtchicky156]

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.

 

[Jon]

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


Jon

 

[killerkeev]

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.

 

[Phridae]

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.

 

[SCEMT-B]

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