EMS providers document patient assessment findings and treatments on an electronic patient care report (ePCR). The report is completed on a tablet, handheld or notebook computer, or smartphone. The format and content of the ePCR collects a similar set of data elements as the paper patient care report they have replaced. ePCRs lead to more consistent data entry, an easier-to-read document, synchronization with a CAD system, improved report delivery, and improved cost recovery.
Here are seven tips to best utilize your service’s ePCR:
1. Develop a system to consistently work through each data entry screen.
2. Confirm the patient’s mailing address as it may be different than the location where the patient is currently residing.
3. Carefully enter patient demographic information, like name, birth date, and social security number, so it synchronizes with information already on file about the patient.
4. Use the body diagram to annotate injury locations, previous injuries, and medical devices (like an ostomy site, pacemaker location, central line port, feeding tube, medication patch, or urinary catheter). You can also mark the location of successful and unsuccessful IV sites.
5. Use a medical documentation technique like SOAP or R-CHART for the patient care narrative.
6. Spell-check and re-read the narrative before submitting.
7. Always review any hand-written notes you made during the patient encounter one final time before synchronizing the ePCR with the data server.
Remember, the ePCR is a reflection of your skills, knowledge and professionalism. Use it to showcase your talents, the careful assessment you performed and the compassionate interventions you delivered to the patient.
This article, originally published on May 28, 2009, has been updated.
