Creating a clinically solid, medically sound, and billing-compliant EMS patient care record is critical not just to patient health, but EMS operational health as well. How is your EMS operations measuring up? How do you use key metrics to improve your EMS data entry and documentation?
A complete and detailed EMS patient care record starts with entering valid EMS data from the point of dispatch. Once the crew completes the patient interaction and care, the process continues with the patient care report (PCR). A patient care report, whether hand-written or entered in ePCR software, serves as an evaluation system of EMS data. The PCR should list the patient’s demographics, location of treatment, symptoms, pertinent negatives (significant symptoms the patient does not exhibit), complete medical history, provided treatments, unprovided standard treatment (and why), and the patient’s billing information.