Hello and welcome to chapter 6 documentation lecture of the emergency care in the streets. Upon completion of this chapter and the related course assignments, you will be able to discuss the purpose of thorough documentation of all aspects of the patient care report, including those applicable to the documentation of the refusal of care. So let's get started. The EMS documentation is an important part of the patient care process. The PCR, which is the Patient Care Report, may be called the pre-hospital care report. It is the only written record of the events that occurred during the call for service. It is a legal record for the call and becomes part of the patient's medical record and the emergency department chart. It allows other healthcare providers to obtain information about what has occurred from start to finish of the call, and helps guide future patient care and quality assurance. An EMS professional needs to know what constitutes a PCR, what information must be included, who might read the report, and when the report must be completed. Also, what terminology may be used. Information can be objective or subjective. Objective information is measurable signs that are observed and recorded, such as blood pressure. Subjective information is information given but that cannot be seen, such as symptoms patients described. An example is the degree of pain. So, try to utilize the patient's own words as much as possible. For every call, the PCR should include objective information and subjective information, also details of patient care. The PCR must be complete, accurate, and legible. It can be the basis of defense in legal proceedings and it facilitates quality and continuity of care. It is also used to bill insurance companies. Now, let's talk about the legal implications of a PCR. Reports may include subjective statements...
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