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7 ePCR documentation tips for EMS professionals

Updated March 5, 2015

Use the ePCR to showcare your skills, knowledge and professionalism

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’s 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 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 ostomy site, pacemaker location, central line port, feeding tube, medication patch, or urinary catheter). You can also mark the location 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.

What about your ePCR tips? Share them in the comments area below!

Greg Friese, MS, NRP, is the Lexipol Editorial Director, leading the efforts of the editorial team on Police1, FireRescue1, Corrections1 and EMS1. Greg served as the EMS1 editor-in-chief for five years. He has a bachelor’s degree from the University of Wisconsin-Madison and a master’s degree from the University of Idaho. He is an educator, author, national registry paramedic since 2005, and a long-distance runner. Greg was a 2010 recipient of the EMS 10 Award for innovation. He is also a three-time Jesse H. Neal award winner, the most prestigious award in specialized journalism, and the 2018 and 2020 Eddie Award winner for best Column/Blog. Connect with Greg on LinkedIn.