New York State Department of Health Policy Statements on Pre Hospital Care Reports

Bureau of EMS Policy Statement
Policy Statement #02-05
Date10/29/02
SubjectPreHospital Care Report
Supercedes/Updates85-01 & 96-01

An essential part of any prehospital medical care is the documentation of the care provided and the medical condition and history of the patient. The Prehospital Care Report (PCR), used as a requirement of Part 800, is the instrument developed and distributed for this documentation. The primary purpose of the PCR is to document all care and pertinent patient information as well as serving as a data collection tool.

The documentation included on the PCR provides vital information, which may be necessary for continued care at the hospital. As part of transferring the patient to the Emergency Department Staff the agency should not leave the hospital until a completed PCR is provided to the appropriate hospital staff.

PCR Use

A PCR should be completed each time the 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.

Information Entry

All information on the PCR should be legible and printed in black ink

Any member of the crew may enter information on the PCR. 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.

On each PCR the following information must be entered:

  • Date of call,
  • Agency Code,
  • Vehicle ID,
  • Dispatch information,
  • Agency Name,
  • Call Location,
  • "Geo" Code,
  • Dispatch information,
  • Type of call: Emergency/Non-Emergency/Stand-by,
  • Time call received,
  • Time service responded,
  • Disposition and disposition code,
  • Patient Name; If no Patient state "No Patient",
  • Patient Date of Birth,
  • Patient Gender,
  • Presenting problem, if more than one, circle the primary problem,
  • Vital signs if a patient was indicated on the form,
  • Chief Complaint,
  • Subjective Assessment,
  • Objective Physical Assessment,
  • Past Medical History,
  • All treatment provided by your agency, do not include treatment provided by other another agency,
  • Crew names, level of certification and NYS certification number.

Distribution

Pink (Hospital Patient Record) Copy:

  • Ambulance Service: Must leave pink copy at the hospital prior to the agency leaving the hospital.
  • Advanced Life Support First Response (ALS FR) Agency:
    • Must be provided to the transport agency prior to the transport agency leaving the scene if no representative of the agency will be accompanying the patient to the hospital.
    • If a representative is accompanying the patient than they must provide the completed copy to the hospital 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: Same as for an ambulance service.
  • Basic Life Support First Response (BLS FR) Agency: BLS FR agencies are not required to use three part PCRs. They may use a two part PCR, available from their Regional EMS Program Agency. BLS FR agencies are not required to submit the research (yellow) copy. If a three part form is used, the research copy may be destroyed by the agency.

NOTE: There are agencies participating in projects submitting data directly to the Department of Health electronically. These are the only agencies exempted from this provision.

White (Agency) Copy

  • All Agencies: The original white copy should be retained in a secure location at the services permanent office as designated to the Department for the following time periods:
    • Federal Law (HIPAA) requires that medical records be retained for Six Years. If the call does involve the treatment of persons under age 18, the PCR must be retained for three years after the child reaches age 18.

Confidentiality & Disclosure Of PCRs/Personal Healthcare Information

Maintaining confidentiality is an essential part of all medical 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.

10 NYCRR (Health) Part 800.21:

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;

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 copies be in writing;
  • That the agency will maintain a copy of the written request with the original PCR;
  • Maintaining the confidentiality of the information contained on a PCR as well as the actual PCRs;
  • 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 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 Disclosures

The PCR 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 simply at the request of a law enforcement or other agency. If a copy of the PCR 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. Except that copies of PCRs 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 completed for themselves as the patient or the parent or legal guardian of a patient may obtain a copy of a PCR 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.

An agency may provide a copy of a PCR 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 indicting 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 is made to provide guidance on many common occurrences.

Issued and Authorized by:
Edward G. Wronski, Director
Bureau of Emergency Medical Services