5 answers
Hayle
Student
1
Question
Updated
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How do can paramedics do reports?
How do you do reports as a paramedic
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5 answers
Todd D. Filener
Medic
7
Answers
Carson, California
Updated
Todd D.’s Answer
PCRs are usually handwritten on paper form (old style) or on ePCR (electronic based.
Rose Eppinette
Ai, emt
13
Answers
Houston, Texas
Updated
Rose’s Answer
Paramedics use reports to record patient care, ensuring smooth communication and consistent care. Here's their usual process:
1. Oral Report:
During the journey: Once they arrive at the hospital, paramedics give a quick oral report to the emergency department staff, usually nurses or triage personnel.
Key Points: The report emphasizes the patient's state, vital signs, treatments given, and any other crucial details.
2. Digital Documentation:
Afterwards: Paramedics fill out a more thorough digital patient care report.
Details: This report records everything from the first call to the handover at the hospital. It outlines the patient's signs, symptoms, medical history, treatments given, and any procedures done.
Advantages: Digital reports have many benefits. They are easy to read, can be accessed by authorized staff, and can be combined with digital health records for better patient care coordination.
Tools and Tech:
Many EMS services use mobile computers or tablets in ambulances, allowing paramedics to write reports digitally on the spot or while in transit.
Here are some more points to consider:
Paramedic reports' specific format and content can change based on local rules and regulations.
Paramedics are taught how to document correctly to make their reports precise, clear, and medically readable.
Keeping data safe and patient privacy is vital. Paramedics follow HIPAA rules to protect patient information in reports.
1. Oral Report:
During the journey: Once they arrive at the hospital, paramedics give a quick oral report to the emergency department staff, usually nurses or triage personnel.
Key Points: The report emphasizes the patient's state, vital signs, treatments given, and any other crucial details.
2. Digital Documentation:
Afterwards: Paramedics fill out a more thorough digital patient care report.
Details: This report records everything from the first call to the handover at the hospital. It outlines the patient's signs, symptoms, medical history, treatments given, and any procedures done.
Advantages: Digital reports have many benefits. They are easy to read, can be accessed by authorized staff, and can be combined with digital health records for better patient care coordination.
Tools and Tech:
Many EMS services use mobile computers or tablets in ambulances, allowing paramedics to write reports digitally on the spot or while in transit.
Here are some more points to consider:
Paramedic reports' specific format and content can change based on local rules and regulations.
Paramedics are taught how to document correctly to make their reports precise, clear, and medically readable.
Keeping data safe and patient privacy is vital. Paramedics follow HIPAA rules to protect patient information in reports.
Ryan Pfeiffer, MA
Firefighter Lieutenant / EMT
97
Answers
Fort Collins, Colorado
Updated
Ryan’s Answer
Hello Hayle,
John's answer is absolutely correct. Reports and documentation are vital in the emergency medical services (EMS), and exactly how they're completed will very slightly depending on who you work for, but the overall process is likely the same.
In the systems I'm currently working in, we differentiate between what we call a "run report" and a patient care report (PCR).
A run report contains no private information about the patient, because it is a matter of public record. It documents things like how you responded to the call, if there were any delays enroute, how long you were on scene, what hospital you transported the patient to, etc.
A PCR is much more detailed and is private medical information. In the PCR we document the patient's age, chief complaint, details about the onset, a description of the pain, notate allergies and medications, record vital signs, and document any interventions we make, like starting an IV and administering a drug to relieve nausea.
The length of each varies on the complexity of the call. I find mine are generally about one page long, and take me around 30 minutes to write. But again, that depends in large part on how many you do, how thorough you choose to be, and how user friendly your employer's system is!
I hope that helps answer your question. Let me know if you have any additional questions, or would like to see some redacted examples of reports!
John's answer is absolutely correct. Reports and documentation are vital in the emergency medical services (EMS), and exactly how they're completed will very slightly depending on who you work for, but the overall process is likely the same.
In the systems I'm currently working in, we differentiate between what we call a "run report" and a patient care report (PCR).
A run report contains no private information about the patient, because it is a matter of public record. It documents things like how you responded to the call, if there were any delays enroute, how long you were on scene, what hospital you transported the patient to, etc.
A PCR is much more detailed and is private medical information. In the PCR we document the patient's age, chief complaint, details about the onset, a description of the pain, notate allergies and medications, record vital signs, and document any interventions we make, like starting an IV and administering a drug to relieve nausea.
The length of each varies on the complexity of the call. I find mine are generally about one page long, and take me around 30 minutes to write. But again, that depends in large part on how many you do, how thorough you choose to be, and how user friendly your employer's system is!
I hope that helps answer your question. Let me know if you have any additional questions, or would like to see some redacted examples of reports!
John Levesque
Clinical Quality Nurse
83
Answers
Waterville, Maine
Updated
John’s Answer
Hey there, Hayle! Each state operates its own EMS systems independently, but you'll find that most of them have embraced the digital age with electronic reporting systems. Picture this: ambulances equipped with laptops or handy tablets that are loaded with special reporting software. This is what most paramedics and EMTs use to record details about their calls.
The kind of information they key in ranges from patient demographics to a concise summary of the call, including any medical interventions or treatments provided. Once they reach the ER or any other destination, like when transporting between facilities, they'll take a few moments to document the call's events. Usually, the crew member who attended to the patient handles this documentation, while the one who drove focuses on tidying up and restocking the ambulance.
During particularly hectic shifts, when calls come in back-to-back without a breather in between, the documentation might have to wait until there's a moment to pause and catch up.
Now, there might still be some areas where old-school paper run sheets or reports are in use, but the overall process remains the same.
Documentation plays a vital role for several reasons, but the most critical one is that it provides a record of the care you provided to the patient. This record is then used for billing, quality assessment, and as a safeguard for you should there be any questions about your actions or if there were any perceived lapses in care.
If you're considering a career in EMS, I'd recommend checking out the links below for some useful information, and also reaching out to your state's EMS office. Best of luck to you!
https://nasemso.org/
https://www.nremt.org/
The kind of information they key in ranges from patient demographics to a concise summary of the call, including any medical interventions or treatments provided. Once they reach the ER or any other destination, like when transporting between facilities, they'll take a few moments to document the call's events. Usually, the crew member who attended to the patient handles this documentation, while the one who drove focuses on tidying up and restocking the ambulance.
During particularly hectic shifts, when calls come in back-to-back without a breather in between, the documentation might have to wait until there's a moment to pause and catch up.
Now, there might still be some areas where old-school paper run sheets or reports are in use, but the overall process remains the same.
Documentation plays a vital role for several reasons, but the most critical one is that it provides a record of the care you provided to the patient. This record is then used for billing, quality assessment, and as a safeguard for you should there be any questions about your actions or if there were any perceived lapses in care.
If you're considering a career in EMS, I'd recommend checking out the links below for some useful information, and also reaching out to your state's EMS office. Best of luck to you!
John recommends the following next steps:
George Opanga
Paramedic
1
Answer
Kisumu, Kisumu County, Kenya
Updated
George’s Answer
As a Paramedic with vast experience in remote site medicine and aeromedical evacuation, I will say that reporting is a continuous process throughout emergent call . It starts from the time you receive the call to post handover period.
There are various schools of thoughts on the format and extent of reporting depending on the country, state, organisation or service delivery company.
All this entities unanimously document their reports in a PCR (Patient care Report) a document that captures the events prior the incidence, interventions made and minute by minute update of the general condition. Therefore it's wise to say there is no specific place not suitable to capture the report. It's captured as management continues.
Once all these data us captured, it become vital in determining the next level of care, from facility, department, health care provider and general management.
There are various schools of thoughts on the format and extent of reporting depending on the country, state, organisation or service delivery company.
All this entities unanimously document their reports in a PCR (Patient care Report) a document that captures the events prior the incidence, interventions made and minute by minute update of the general condition. Therefore it's wise to say there is no specific place not suitable to capture the report. It's captured as management continues.
Once all these data us captured, it become vital in determining the next level of care, from facility, department, health care provider and general management.