- The complete EMS documentation associated with an EMS events service delivery and patient care shall be electronically recorded into a Patient Care Report (PCR) within 24 hours of the completion of the EMS event with an average EMS Data Score of 5 or less.
- The EMS documentation of a Patient Care Report (PCR) is based on the appropriate and complete documentation of the EMS data elements as required and defined within the South Carolina EMS Standards. Since each EMS event and/or patient scenario is unique, only the data elements relevant to that EMS event and/or patient scenario should be completed.The EMS Data Score is calculated on each EMS PCR as it is electronically processed into the South Carolina PreHospital Medical Information System (PreMIS). Data Quality Scores are provided within PreMIS and EMS Toolkit Reports. The best possible score is a 0 (zero) and with each data quality error a point is added to the data quality score.
- A complete Patient Care Report (PCR) must contain the following information (as it relates to each EMS event and/or patient):
- Service delivery and Crew information regarding the EMS Agency’s response
- Dispatch information regarding the dispatch complaint, and EMD card number
- Patient care provided prior to EMS arrival
- Patient Assessment as required by each specific complaint based protocol
- Past medical history, medications, allergies, and DNR/MOST status
- Trauma and Cardiac Arrest information if relevant to the EMS event or patient
- All times related to the event
- All procedures and their associated time
- All medications administered with their associated time
- Disposition and/or transport information
- Communication with medical control
- Appropriate Signatures (written and/or electronic)
- The purpose of this policy is to:
- Promote timely and complete EMS documentation.
- Promote quality documentation that can be used to evaluate and improve EMS service delivery, personnel performance, and patient care to the county’s citizens.
- Promote quality documentation that will decrease EMS legal and risk management liability.
- Provide a means for continuous evaluation to assure policy compliance.
- The following procedures shall be implemented to assure policy compliance:
- The EMS Patient Care Report (PCR) shall be completed as soon as possible after the time of the patient encounter. Documentation should be completed prior to leaving the destination facility unless call demand dictates otherwise, in which case documentation must be completed prior to the end of the personnel’s shift.
- The PCR must be completed in the PreMIS System or electronically submitted to the PreMIS System within 24 hours of the EMS event or patient encounter’s completion. The EMS data quality feedback provided at the time of the electronic submission into PreMIS should be reviewed and when possible any identified errors will be corrected within each PCR. Each PCR may be electronically resubmitted to PreMIS as many times as needed.
- The EMS Data Quality Scores for the EMS System, EMS Agency, and individual EMS personnel will be reviewed regularly within the EMS System Peer Review Committee.