Prehospital Care Reports

Bureau of EMS Policy Statement
Policy Statement # 12-02
Date January 23, 2012
Subject Prehospital Care Reports
Supercedes/Updates 85-01, 96-01, 02-05

Documentation is an essential part of all prehospital medical care. It must include, but not be limited to the documentation of the event or incident, the medical condition, treatment provided and the patient's medical history. The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool.

Article 30, section 3053 of the Public Health Law requires all certified EMS agencies to submit PCR/ePCRs to the Department. The completion of a PCR is a requirement for all certified EMS providers in accordance with Title 10 NYCRR Part 800.15. This also includes all of the electronic PCR (ePCR) programs. While Basic Life Support - First Response (BLS-FR) agencies are not specifically required to submit PCR/ePCR data, their participation in the EMS system, quality assurance and data collection are critical to system management and patient care. All BLS-FR agencies are encouraged to submit EMS data through the Regional Program Agencies.

The documentation included on the PCR/e-PCR provides vital information, which is necessary for continued care at the hospital. As part of transferring the patient to the Emergency Department Staff the agency must provide an appropriate medical record that includes the demographic, event/incident, assessment findings and treatment details upon delivery of the patient.

PCR/ePCR Use:

A PCR/ePCR should be completed each time the EMS agency is dispatched for any type response. This includes (but is not limited to):

  • Patients transported to any location,
  • Patients who refuse care and/or transport,
  • Patients treated by one agency and transported by another,
  • Calls where no patient contact is made, such as
    • Calls cancelled before reaching the scene
    • Calls where no patient is located
    • When dispatched for a stand by
    • Events

If an agency is dispatched to a stand-by and while there they treat a patient, two PCRs should be completed. One as a record of the event and one for the patient care provided.

Information Entry:

All information written on the paper PCR should be legible and printed in blue or black ink.

Any member of the crew may enter information on the PCR/ePCR. The individual indicated as "In Charge" should be the person who provided or directed the care to the patient. There is no requirement that the person in charge be certified as the highest level of care present. However the individual indicated as in charge is responsible for the care provided and documented. The provider listed as "In Charge" must be at least an EMT. If any advanced life support care was provided to the patient, the provider listed as "In Charge" must be an advanced EMT at the level appropriate for the care provided.

A complete PCR/e-PCR must include the fields required by the New York State Data Dictionary. The complete data dictionary can be found at the following URL:

Distribution of Paper PCRs:

Pink (Hospital Patient Record) Copy:

  • Ambulance Service: Leave the "pink" copy at the hospital prior to the agency leaving the hospital. In instances where this is not possible, all attempts should be made to provide the completed document to the receiving hospital as soon as reasonably possible. However, the ambulance crew must provide an appropriate medical record that includes the demographic, event/incident, assessment findings and treatment details upon delivery of the patient to the receiving facility.
  • Advanced Life Support First Response (ALS FR) Agency: If no representative of the ALS agency will be accompanying the patient to the hospital, the transporting agency must be provided with an appropriate medical record that includes the demographic, event/incident, assessment findings and treatment details, if possible prior to leaving the scene. If an ALS provider is accompanying the patient than they must provide the completed medical record to the receiving facility prior to leaving (as above).
  • Basic Life Support First Response (BLS FR) Agency: Same as for ALS FR Agency.

Yellow (Research) Copy:

  • Ambulance Service: Yellow copy shall be submitted by the service to the Regional EMS Program Agency as designated by the Department. PCRs shall be submitted at least monthly, or more often if so indicated by the program agency.
  • Advanced Life Support First Response (ALS FR) Agency: Yellow copy shall be submitted by the service to the Regional EMS Program Agency as designated by the Department. PCRs shall be submitted at least monthly, or more often if so indicated by the program agency.
  • Basic Life Support First Response (BLS FR) Agency: While not required by statute, the yellow copy shall be submitted by the service to the Regional EMS Program Agency as designated by the Department. PCRs shall be submitted at least monthly, or more often if so indicated by the program agency

White (Agency) Copy:

  • All Agencies: The original white copy should be retained in a secure location at the service's permanent office as designated to the Department for the following time periods:

NOTE: Federal Law (HIPPA) requires that medical records be retained for Six Years. If the call involves the treatment of persons under age 18, the PCR must be retained for three years after the child reaches age 18.

Electronic PCRs (ePCR):

  • EMS services are required to leave a paper copy or transfer the electronic PCR information to the hospital prior to the EMS service leaving the hospital. This document must minimally include, patient demographics, presenting problem, assessment findings, vital signs, and treatment rendered.
  • Failure to leave patient information with the emergency department upon the delivery of the patient may compromise medical treatment and interrupt the continuity of patient care.
  • All electronic patient records should be completed and closed prior to the end of the shift during which the patient was treated. There should be no access to patient records on personally owned computers. Agencies should have policies restricting the use of personally owned computers for completing ePCRs.

Confidentiality & Disclosure of PCRs/Personal Healthcare Information:

Maintaining confidentiality is an essential part of all health care, including prehospital care. The confidentiality of personal health information (PHI) is covered by numerous state and federal statutes, Polices, Rules and Regulations, including the Health Insurance Portability & Accountability Act of 1996 (HIPAA) and 10 NYCRR.

Title 10 NYCRR Part 800.15:

Every person certified at any level pursuant to these regulations shall:

  • (a) At all times maintain the confidentiality of information about the names, treatment, and conditions of patients treated except:
  • (1) A prehospital care report shall be completed for each patient treated when acting as part of an organized prehospital emergency medical service, and a copy shall be provided to the hospital receiving the patient and to the authorized agent of the department for use in the State's quality assurance program;

Title 10 NYCRR Part 800.21:

An ambulance/ALS-FR service shall:

  • (l) maintain a record of each ambulance call...

Health Insurance Portability & Accountability Act of 1996 (HIPAA):

Federal Law (HIPAA) requires all healthcare providers to have a written policy on protecting Personal Health Information (PHI), including PCRs.

Such a policy should include (but not be limited to):

  • Indicate that requests from patients for PCR/ePCR copies be in writing;
  • That the agency will maintain a copy of the written request with the original PCR/ePCR;
  • Maintaining the confidentiality of the information contained on a PCR/ePCR as well as the actual PCR/ePCR;
  • Conducting security training for all employees/members in proper security procedures to protect personal health information; and
  • Documenting security training of employees/members.

Providing PCR/ePCR copies to the receiving hospital, other providers giving care in a tiered system and to the EMS program agency for QI does not constitute a violation of the HIPAA regulations. For additional agency specific questions regarding HIPAA agencies should contact their legal counsel and/or the U.S. Department of Health and Human Services.

Other PCR/ePCR Disclosures:

The PCR/ePCR may also serve as a document called upon in legal proceedings relating to a person or an incident. No EMS agency is obligated to provide a copy of the PCR/ePCR simply at the request of a law enforcement or other agency. If a copy of the PCR/ePCR is being requested as part of an official investigation the requestor must produce either a subpoena, from a court having competent jurisdiction, or a signed release from the patient. PCR/ePCR must be made available for inspection to properly identified employees of the NYS Department of Health.

A person may request a copy of a PCR/ePCR completed for themselves as the patient or the parent or legal guardian of a patient may obtain a copy of a PCR/ePCR completed for that patient. In cases where the patient is now deceased the person who is the court appointed legal representative of the patient's estate may request a copy of the PCR/ePCR.

An agency may provide a copy of a PCR/ePCR to those entities that represent that agency either for the purpose of collection of fees from the patient or their insurance carrier or as part of any legal proceedings relating to the agency. In such situations those representative are also responsible for protecting the personal health information contained within the document.

Disposition Codes:

All hospitals in New York State have a three digit code indicating the hospital. In addition the name of the hospital must be indicated.


Non Hospital
Disposition
Codes
Meaning Example(see Note)
001 Nursing Home Any nursing home, rehabilitation center, respite home or extended care facility not listed with a hospital disposition code.
002 Other Medical Facility Includes outpatient and specialty clinics, doctor's offices, diagnostic and testing facilities.
003 Residence When a patient is transported to a private residence.
004 Treated By This Unit & Transported By Another Unit In a multi tiered response system this disposition would be used by any BLS FR or ALS FR agency. This code would also be used if one ambulance service provides ALS interface for another ambulance. It would not be used by multiple vehicles from the same agency i.e. two ambulances are dispatched to the same call.
005 Refused Medical Aid and Or Transport Any time contact is made and a person is evaluated, to include such procedures as vital signs being taken, or any treatment is provided. The documentation included on the PCR must indicate that the patient was advised of the need for care and the patient was competent to make an informed refusal of such care.
006 Call Cancelled Any time a call is canceled prior to the arrival of the EMS agency this disposition code should be used. When possible the crew should document what other agency canceled the response or the reason for the cancellation.
007 Stand By Only (No Patient) Used if a service is dispatched for a call such as to stand by during a fire or other incident. If any person is treated at the scene an additional PCR should be completed for them.
008 No Patient Found If a service arrives at a scene and there is no one there with any complaint or injury, this code should be used. This would include being dispatched to a motor vehicle crash at which there are no persons who require any evaluation or care to. Document completely under Comments
010 Other Any instance not indicated or explained above. This might include a lift assistance call for a person who has fallen. Document completely under Comments

NOTE: It is impossible to include every possible scenario. An effort has been made to provide guidance on many common occurrences.