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SPECIAL CASE DOCUMENTATION
MULTIPLE-CASUALTY INCIDENTS (MCI)
Multiple casualty incidents present challenges to EMS documentation caused by an overwhelming number of patients.
When there is not enough time to complete the form before the next call, the EMS professional will need to fill out the patient care report in its entirety later.
The local MCI plan should have some means of recording important medical information temporarily, and each EMS professional should be familiar with this system. The standard for completing the patient care report form in an MCI is not the same as for a typical call.
SPECIAL SITUATION REPORTS
Sometimes, special situations are encountered that require additional documentation such as provider exposure and injury.
Special situation reports are used to document events that should be reported to local authorities or to amplify and supplement a primary report.
These forms should be submitted in a timely manner and should include the names of all agencies, people, and facilities involved. Special situation reports should be accurate and objective, with the EMS professional making sure to be descriptive but not state conclusions.
The EMS professional should keep a copy of the special situation report for his/her own records as appropriate. The report, and copies, if appropriate, should be submitted to the authority described by the local protocol.
All interfacility transfers require documentation that includes
- the reason for the transfer,
- any and all treatment provided prior to arrival of the transporting EMS professionals,
- a full assessment,
- any treatment provided while en route to the receiving facility and whether that treatment was scheduled or unanticipated, and
- the condition of the patient upon arrival at the receiving facility.
Interfacility transfer documentation, just like other patient care report documentation, should
- include body systems documentation,
- body parts documentation,
- documentation of the clinical impression/working diagnosis,
- documentation of any treatments and the response to that treatment, and
- documentation of transferring patient care to another provider.
OTHER USES OF THE PCR
Information gathered from the prehospital care report can be used to analyze various aspects of the EMS system, and can then be used to improve different components of the system and prevent problems from occurring.
An EMS professional should provide the receiving facility a basic report known as a drop report or transfer report, complete with a minimum data set that includes
- chief complaint,
- treatment rendered and changes in patient condition, as well as,
- a transfer of care signature prior to departing from the hospital.
An EMS professional should keep a copy of this drop/transfer report for use as a reference during the primary prehospital care report and should submit the copy with the final prehospital care report.