PCR sample

Should you complete a PCR even if you completed a worksheet or mini PCR?

A PCR documents care provided to a patient before they arrive at the hospital.
The PCR forms are provided by NYS DOH and are to be completed at the end/during patient care.

Documentation is an essential part of all pre-hospital care. It must include, but not be limited to the documentation of the event or incident, the medical condition, treatments provided, the patients’ response to treatments and the patient’s medical history. The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool.

The documentation included on the PCR provides vital information, which is necessary for continued care at the hospital. As part of transferring the patient to the Emergency Department Staff the agency must provide an appropriate medical record that includes the demographic, event/incident, assessment findings and treatment details upon delivery of the patient.

A PCR should be completed each time the EMS agency is dispatched for any type response. This includes (but is not limited to):

*Patients treated
*Patients transported
*Patients who refuse care and/or transport
*Patients treated by one agency and transported by another
*Calls where no patient contact is made, such as
*Calls cancelled before reaching the scene
*Calls where no patient is located
*When dispatched for a stand by
*Special events

What to do with the three carbon copies of a PCR (paper version)?
AGENCY COPY:      (White) Remains with responder’s department/agency.
RESEARCH COPY: (Yellow) Send the previous months PCR’s to your Program Agency
postmarked by the 10th of each month (example; March 2014 PCR’s are
due to EMSTAR by April 10, 2014)
HOSPITAL PATIENT COPY: (Pink) To the hospital with the patient.

Article 30, section 3053 of the Public Health Law requires all certified transporting EMS agencies to submit PCR/ePCRs to the Department. The completion of a PCR is a requirement for all certified transporting EMS providers in accordance with Title 10 NYCRR Part 800.15. This also includes all of the electronic PCR (ePCR) programs. While Basic Life Support – First Response (BLS-FR) agencies are not specifically required to submit PCR/ePCR data, their participation in the EMS system, quality assurance and data collection are critical to system management and patient care. All BLS-FR agencies are encouraged to submit EMS data through the Regional Program Agencies.

Providing PCR/ePCR copies to the receiving hospital, other providers giving care in a tiered system and to the EMS program agency for QI does not constitute a violation of the HIPAA regulations. For additional agency specific questions regarding HIPAA, agencies should contact their legal HIPAA Officer/or the U.S. Department of Health and Human Services.

The PCR/ePCR may also serve as a document called upon in legal proceedings relating to a person or an incident. No EMS agency is obligated to provide a copy of the PCR/ePCR simply at the request of law enforcement or other agencies. If a copy of the PCR/ePCR is being requested as part of an official investigation the requestor must produce either a subpoena from a court having competent jurisdiction, or a signed release from the patient. PCR/ePCR must be made available for inspection to properly identify employees of the NYS Department of Health.

If an agency is dispatched as stand-by and while there they treat a patient, two PCRs should be completed. One as a record of the event and one for the patient care provided.

The bottom line is, EMS First personnel provide care to patients. Their documentation reflects the evidence of the care given. This document becomes part of their permanent medical record at the receiving hospital. The documentation meets the legal requirements, protecting providers in the event of a lawsuit, by providing the accurate happenings at the scene. It also meets the QI requirements. The PCR is also a record of who was at the call and potentially exposed to communicable/infectious diseases. The infection control staff at the hospitals knows that the PCR will contain the names of the personnel involved.

For further information on writing an effective PCR, please contact EMSTAR 607-732-2354 x103.