DB 16-10 - Electronic Patient Care Report (ePCR) Requirements

Question 1

The Emergency Medical Services Bureau (EMS Bureau) has revised policies for generating ePCRs.

These revisions will:

Answer 1

-significantly reduce number of required ePCRs
-improve operational efficiency
-eliminate unnecessary reports
-increase billing

Question 2

Accurate, complete, and thorough documentation of every patient encounter is mandated by the California _________.

Answer 2

Health and Safety Code

Question 3

Resources attached to an EMS incident DO NOT need to generate an ePCR under the following circumstances:

Answer 3

1. Canceled:
   a. Any company “returned by radio” by MFC while en route.
   b. Any company canceled while en route or on scene by another resource.
2. Stand-by:
   a. Any type of stand-by incident with no patient contact.(Examples: structure fires, MCIs, or law enforcement standby’s (INVEST P) where there is no patient contact. This DOES NOT include a single patient incident with “no patient found.”)
3. Basic assistance to transporting Rescue Ambulance (RA) only:
   a. Fire companies or BLS RAs responding with a paramedic RA in which only basic assistance was provided alongside the transporting RA (taking vitals). Only company handling the incident (or transporting patient) shall complete ePCR.
   ** Basic RA assistance does not apply to companies that arrive ahead of a transporting resource and initiate assessments and/or perform treatments.**

Question 4

All other current ePCR documentation requirements continue to remain in place, including “false” and/or “no patient found”. These incidents still require the completion of an ePCR, unless?

Answer 4

cancelled by MFC or another resource that is on scene.

Question 5

“Los Angeles County Prehospital Care Policy Manual”, Reference 606 defines a patient who requires medical documentation as, “______________.”

Answer 5

A person who SEEKS or APPEARS to require medical assessment and/or medical treatment

Question 6

Station Commanders shall confirm all ePCRs for each of their assigned units are properly exported by _____ hours each morning.
The findings of each morning check shall be documented in the station journal.

Any ePCRs unable to be exported shall be immediately reported to the on-duty _______ for necessary technical assistance and the _______ shall also be notified.

Answer 6

-0800hrs

-EMS Battalion Captain

-Administrative Battalion Chief

Question 7

Once at the hospital, when shall members who transported a patient complete their ePCR?

Answer 7

Prior to leaving the hospital.

(All other ePCR reports – i.e., non-transports, or any ePCRs completed by nontransporting resources — shall be completed AS SOON AS PRACTICAL and exported by the END of each shift.)

Question 8

At the beginning of each shift, responsible ePCR members shall:

Answer 8

• Restart their assigned ePCR device and log into MobileTouch

• Enter a session and select their vehicle for the shift

Question 9

In the event of ePCR hardware failure while assigned to an EMS incident, members shall not compromise patient care and are directed to take the following actions:

Answer 9

a) Continue with all appropriate patient care.

b) Request an EMS Captain be added to the call.

c) Produce written notes necessary to complete an ePCR upon immediate failure resolution.

d) Transfer all information to create an ePCR as soon as possible and attach all LifePak data

e) The EMS Captain shall ensure that all paper copies of patient care data acquired during this time are shredded in accordance with HIPAA.

Question 10

Members shall immediately notify their EMS Battalion Captain to exchange/replace a malfunctioning or lost ePCR device. During this time, units shall remain ______ (AVI,CAV,NAV?)

Answer 10

AVI available

(use of NAV status to specifically secure an operable ePCR device SHOULD be avoided.)

Question 11

Members completing ePCRs and responsible for patient documentation shall enter the following information in the F-2 Journal as the patient care record:

Answer 11

• Incident number

• ePCR Booklet Number (12-digits)

• Incident time of dispatch

• Type of Incident

• Resources assigned to the incident

• Address of incident

• Services provided and incident disposition (e.g., treatment, hospital transportation location, etc.)

• Time available

Question 12

Members may receive electronic feedback and/or a previously submitted ePCR may be returned for necessary correction from the EMS Bureau or EMS Quality Improvement Unit.
Any ePCR returned for correction shall be addressed within what timeframe?

Answer 12

immediately upon receipt.