Ems PT Care Report

Question 1

PCR Narrative: only approve JFRD format

Answer 1

• CC (chief complaint)
• HPI (history of present illness)
• PE (physical exam)
• TX (treatment)
• Note

Question 2

HPI (history of present illness)

Answer 2

•how PT presented upon arrival
•description of why PT called 911
(Onset and activity related to the complaint)
•detailed description of the complaint

Question 3

PE (Physical Exam)

Answer 3

• evaluate objective anatomic findings through the use of Observation, Palpation, Percussion, and Auscultation
• include Location, Quality, Pain scale, Duration and any associated signs and symptoms that relate to present illness
• include the pertinent positive and negative findings

Question 4

TX (Treatment)

Answer 4

Document:
• how PT was moved to stretcher and details of the ER transfer. Include the staff member’s name that received PT

• any changes in PT condition that occurred during transport and transfer to hospital
• for PT refusal (AMA), the following statement must be documented___________

Question 5

Note:

Answer 5

This additional section will be used for any unusual circumstances that occur during the entire duration of the incident. (e.g. PT contact delays, scene delays, PT/family issues, equipment issues, transfer of care issues, etc

Question 6

“AMA REFUSAL” and “NON-EMERGENCY-TRANSPORT”

Obtain and record:

Answer 6

•at least one set of vitals
•improvement
•perform physical exam
•PT is oriented times 4
~ access for medical illness that could alter
MS
~ assess for psychiatric illness
~ assess for toxic ingestion(boos and drugs
•asses for competency of PT
~ => 18 or emancipated minor
~ awake and alert times 4
~ not under the influence of drugs or boos
•care maybe refused for a minor only if all:
~ PT exhibits no historical or physical
Findings of potential life, limb, organ
Threatening injury or illness
~ PT is not intoxicated and alteration of
Metal status, level of consciousness
or vital signs
~ the responsible parent/legal guardian are
present
•if PT is not competent to refuse
~ explain the need for transport
~ reassure no harm will result
•if PT continues to refuse and satisfies FS
40.445 “Emergency examination and
Treatment of incapacitated persons
~ I lost the aid of law enforcement for PT and
Crew safety
~ proceed with PT transport
•if competent to refuse
~ the usual
•document on PCR:
~ all cases in which there is a refusal of care
~ “ “ an assessment of competency
~ all refusal language
~ name of PT
~ signature
~ if refused document “Refused to Sign”
- print name, signature, and phone
Number of competent witness

Question 7

Appropriate witnesses in order of preference:

Answer 7

Spouse 
Relative 
Law enforcement 
Friends 
Other fire/rescues personnel

Question 8

Who can not sign as a witness of Refusal?

Answer 8

JFRD officer who is documenting and executing the legal refusal

Question 9

Signed refusals on the EMS field copy will only be completed when? And filed where?

Answer 9

• laptop failure

* filed at the station

Question 10

Refusal signatures shall be acquired on the laptop, any circumstances in which the laptop is unavailable or not functioning, the OinC will select________ as the reason for not obtaining a signature. If a laptop technical issue occurs, a _________ must be completed and include all of the following:

Answer 10

~”Laptop Technical Issues”

~ full field copy report with appropriate signatures

~ all info you would expect and one set of vitals
Including pulse, resp. rate, BP, sugar, SAT
and GCS, signature on back and witness with
name, signature and phone number

Question 11

Completed paper refusals will be forwarded to who? How often?

Answer 11

• Quality Improvement Office

* once a year