1. This document provides instructions for completing electronic patient care reports (ePCRs) in the GFD ambulance reporting system.
2. It describes how to log in, select an incident to start a new report, and access existing reports.
3. The document outlines how to fill out various sections of the ePCR like assessments, narratives, signatures and validate the completed report.
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3. Log In
1. User Name: first
initial, last name.
ex: Smacaluso
2. Password: your
chosen
password. Log in
periodically and
remember,
passwords expire
every 90 days.
3. Agency: GFD
(ambulance
medics use
TRICITY)
4. * Select Add ePCR incident to
add a new report
* Clicking ePCR will give you
access to existing reports. A new
report can also be generated
from that screen
19. This will bring up your GCS, Revised Trauma Score and Pediatric Trauma Score
Charts. These should be entered on patients complaining of pain, traumatic injury,
falls, loss of consciousness, head injuries, altered level of consciousness,
drug/alcohol intoxication or overdose or anything you feel pertains to this. It is
especially important in the event of an improvement, worsening symptoms or any
pertinent changes during assessments.
20. This should be used for any patient complaining of pain. If patient does not
or is unable to rate pain, document that and this can be left blank
25. After you have entered in your
treatments, your treatment screen
under flow charts will resemble this
(obviously, this depends on what, if
any, treatments you have done.)
27. You may chose to click on
each one of these individually
and fill them out or you can
also click the tab on the right
titled Assessment Details.
You can select No
Abnormalities (if applicable)
or not assessed on each one.
If there is something you
found in your assessment
that needs to be noted, just
click on the white box on the
top right of your chosen
assessment category.
29. If you do have something pertinent to note in
your assessment section, after you have
opened the category, here we chose
Extremities, this screen will show up and you
need to specify your findings. Make sure
anything unfounded gets marked as No
Abnormalities.
Here we have that during our assessment
the patient was found to have left arm
weakness and ‘other’ is selected. If you were
to scroll down, you would see a comments
section where you would specify any
abnormalities found.
31. At the top of the narrative page, you will see these two sections. Please fill
them out accordingly. Remember, if you select Yes patient was injured, you
need to complete the other boxes.
32. Your narrative should be typed
under the Narrative section. The
section marked Appended
Narrative is for addendums.
35. • Billing and Signatures tab are typically for transported
patients. However, patients that are treated and released, like
a diabetic patient, need to have that documented here. There
are multiple options. Transported patients also have loaded
miles documented here.
• Signatures are obtained by the transporting crew using their
laptops. If unable to use laptop, paper copies are available for
signatures.
36. 1. Your almost done, just a few more steps! Make sure to validate
every report once completed. Click the green check mark at the top of
the page and follow the prompts to continue with validation.
2. Once the ‘Confirm’ box shows up, select OK.
3. A second confirmation box will appear, click OK
** Important Note: Once you have clicked the check mark, if you have anything incomplete, it will prompt you and will
not let you continue until it is done. Make sure all of your necessary and pertinent information is filled in ALL fields.
Once you validate you cannot changes. If something needs to be changed, you will need to document in the
Appended Narrative section what needs to be added, removed or otherwise changed and why. The program will time
and date stamp any changes made.
37. Printing Reports
1. Only one copy is needed for releases and transfer of care reports to be filed with NFIRS. If patient is
transported, the ambulance crew will print two of their reports, one to leave at ER and one for FD
filing and will be attached with NFIRS report.
2. To print, just click the icon that looks like a printer at the top right.
3. You will then see a screen prompting you to select which type of report to print. For a transfer of
care report or release obtained by engine companies, choose the Patient Care Report. (Billing PCR
is used for transporting ambulances) The Refusal option is when the ambulance personnel obtains
a refusal using their laptops.
38. After you have selected your print
option, you will see a print preview
screen similar to this. Please note how
this example says Draft at the top. Your
report is incomplete if it says draft.
You’ll need to exit preview screen and
make sure your report has been
validated and locked.
Once it’s appropriately validated, you
won’t see the Draft indicator, click the
printer icon on your top left and it will
be printed.
39. • EMT-B’s and Paramedics both can obtain a basic release/MPR. Release should be obtained on all EMS related calls when
patients are not being transported.
• Minor patients cab be released BUT Delnor must be contacted and guardian should be on scene to sign release. OLMC may
allow release if parent/guardian has been spoken to over the phone.
* Important definitions/description per SFVEMSS protocol:
Refusals: Patients who are judged to be legally and mentally decisional have the right to refuse any and all treatment. Patients who are non-decisional may not consent to or refuse treatment.
Minors: Patients who are minors (<18) should have consent of a parent or guardian obtained prior to treatment unless they qualify as an emancipated minor or qualify for care under implied consent
under the Emergency Doctrine. See System-specific policies regarding notification of parent or guardian if they are not immediately available.
Physicians on scene: May offer their services and direct patient care only when an Illinois M.D. or D.O. physician’s license is shown. The physician must accompany the patient to the hospital. OLMC
must be contacted immediately and the scene physician shall discuss the case with the ED physician. EMS personnel must not exceed their scope of practice to comply with the requests of an on-scene
physician.
Consent: Decisional adults must consent to treatment. Consent must be informed or clearly implied via verbal agreement to the treatment or gestures indicating their desire for treatment. A
patient's lack of refusal or physical resistance or withdrawal will be taken as consent.
Consent (Implied): Patients who are unconscious or otherwise so incapacitated that they cannot comply with the above provisions and do not exhibit the ability to make sound judgments, will be
treated under implied consent. Patients who are obviously impaired with altered judgment who are unable to understand their decisions, have slurred speech, and/or ataxia; those suffering from
mental illness; those who have made suicidal/homicidal statements (to EMS personnel or persons physically present at the scene who will attest to the statements on a petition form) are to be
treated under the doctrine of implied consent. They are not allowed to refuse treatment or transport.
Abandonment: No patient with continuing medical needs shall be abandoned. Abandonment includes executing an inappropriate refusal, releasing a patient to a less qualified individual or
discontinuing needed medical monitoring before patient care is assumed by other professionals of equal or greater licensure than the level of care required by the patient.
40. Multiple Release (MPR)
- MPR’s are used in situations where 2 or more patients
are found and they do not require or request any further
medical treatment/transport and have no complaints.
However, if for example you go to a MVC with 5 patients
and 4 are uninjured and have no complaints, but one
patient does have a complaint, that one patient needs an
individual release, the rest can go on an MPR. This is per
SFVEMSS.
- Pt’s must be 16 y/o or older. (Minor patients still require
that Delnor be contacted.)
- When obtaining your information, please remember to
get a date of birth (the form only asks age).
- If incident is a MVC, please try to note in comments
location and extent vehicle damage, airbag deployment,
if patient was restrained etc.
- Sign the bottom and have your partner or other person
sign as well.
41. Individual Release
Uses:
1. For patients that treatment/transport is recommended
and they refuse treatment/transport.
2. Patients not requiring/requesting emergency
transport/treatment.
3. Patients refusing specific treatments. Please check all that
apply or add in the specified area.
4. Patients refusing recommended transport to closest
hospital.
5. MD’s assuming care and accompanying pt. during
transport.
* Remember to obtain and document vitals (per sfvemss)
* All minor age releases must be called in to Delnor prior to
releasing and guardian should be on scene to sign.
* Ideally, try to get a witness signature from family, friends,
persons remaining with patient etc. If unable, use PD, FD or
other EMS personnel.
* If patient refuses to sign refusal, complete bottom portion.
Patient/guardian must print on the top line, initial appropriate
option and sign at the signature line towards the bottom.
Pt prints name
Patient or
guardian
should
initial all
that apply.
Pt’s or pt representative signature