Week 4- ACR Orientation Program Flashcards
What documentations do we have to follow?
- Ambulance act- documentation
- MOH documentation standards
- EMS employer policies/ Procedures & Practices
- MOH ACR Completion Manual
MOH Documentation Standards- Reports required under this standard may be made in either:
- Written or electronic format
- Ensure completed reports remain readable and readily accessible for review for at least 5 yrs from the date of the collision, incident or patient care even documented
- Information contained in reports made under this standard will be of a completeness
- And quality suitable for use as evidence in an investigation or legal proceeding
- Where a document under this standard contains information that could identify a person who is a patient, the report and the information contained therein is subject to the confidentiality provisions of the Ambulance Act and shall be secured from unauthorized access
Who completes the ACR?
- The patient care provider who assessed and/or has rendered patient care is responsible for completing the patient care documentation for the person whom he or she assessed or to whom care was provided
- The paramedic is called the “Attendant” & is the medic with the highest level of training as deemed necessary for proper care on a call
When is an ACR required?
- An Ambulance Call Report will be completed for each request for ambulance service where a “patient” was assessed whether or not care was provided or the person was transported by ambulance or emergency response vehicle
What is the importance of an ACR?
- Clinical Information: call hx/ pt. assessment & findings/ pt’s response to tx. All this is important to Receiving facilities were “on going” care is performed
- Administrative: provided statistics which assist in maintaining effective ambulance services & care
- Research: QA process for advancement in prehospital care
- Legal: as part of an investigation or legal proceedings
Definition of Patient
- a person whom request for ambulance services was made & whom the Paramedic has made contact with for purpose of care, or transport- regardless of whether or not an assessment is conducted or pt. care provided or transport occurs
Definition of eACR
- Electronic ambulance call report. Is equivalent to a paper ACR
Definition of Call
- request for an ambulance service
Who is a patient?
“Patient” means a person who,
(a) receives first aid, emergency or other medical care from an emergency medical attendant or paramedic, or
(b) is transported in an ambulance by an emergency medical attendant paramedic
What are the 5 areas of the ACR?
- Demographics
- Clinical information
- Physical exam
- Clinical Tx/ Procedures & results
5.General administration
Reverse Side of ACR
- Acceptable codes to correspond to various areas- for statistical reasons
- Reference information: to provide clarity & guidance for documentation- ie. “pain scale”
- Aid to capacity evaluation: refers to whom your evaluation/ assessment is done/ & or if not your pt
- Refusal of service: to be completed every time a pt refuses a tx/ procedure or transport
Electronic “ePCR”
- Electronic patient care report
- Completed on a computer
- Includes a “self check” to ensure area are completed
- Complies with the same doc. rules
ACR Prompts
- Prompts are “check boxes”
- These check boxes allow paramedics to indicate quickly by checking commonly documented finding & or information
-“Ghosted Scripts”- fields requiring dates or times- allows for consisted documentatio
Completion Requirements
Collection of Biometric Data- “physiological” vs behavioral data
- vital signs
- ECG
- CPR data
- SPO2/ ETCO2 values/ measurements
Where does the ACR go?
Copies of completed ACR for all pt carrying and pt refusal of service calls will be distributed within 48 hrs of completion of the call, as follows:
- Original copy “pt chart”: will be left with the receiving hospital staff/ coroner who is taking over responsibility for the pt
- Billing copy: will be distributed to the department or office that is responsible for billing (usually receiving hosp)
- Base hospital copy: as designated will be distributed to the base hospital- often for QA process & data collection
- Ambulance service copy: as designated will be retained by the service operator for their records- kept for 5 yrs min
