Effective: 12-16-22
Supersedes:
Purpose: In order to ensure compliance with state regulations and company policies, field crews are to complete and synchronize their ePCR prior to clearing from the transport destination. The organization’s goal is for 100% trip synchronization prior to the completion of a patient transport.
Policy: All field crews are to complete and synchronize their ePCR prior to clearing from the transport destination unless dispatched to another emergency response. In that case, the unsynchronized ePCR will be completed once clear from the emergency response and prior to returning to base. Your ePCR must include:
o All Patient Demographics
§ Name
§ Date of Birth
§ Home Address
§ Telephone Number
§ Social Security Number (if available)
o Patient Insurance information
o A Chief Complaint and Primary Impression that reflects the reason for ambulance transport
§ The chief complaint is the medical reason the patient needed an ambulance at the time of transport.
· “Facility Discharge” is not a chief complaint.
· “Bed Confined” is not a chief complaint- rather, describe what medical condition caused the patient to be bed bound
o A detailed narrative that includes information as to the patient’s condition at the time of transport and supports the patient’s Chief Complaint.
o All Patient and Facility signatures.
§ Patients themselves must sign unless they are legitimately unable to (minors, unresponsive, etc.)
§ If a patient is unable to sign for themselves, you must document the reason why in your narrative
o A completed Medical Necessity when appropriate
911 Providers –
o All efforts are to be made to obtain all patient demographics by direct patient dialogue, family members, review of patient ID’s/insurance cards if available, and hospital registration
o Language barriers are addressed by reviewing ID/insurance cards and obtaining and submitting the face sheet from the receiving facility, prior to clearing the facility.
o If due to the patient’s acuity or lack of ID (J. Doe patients) you are unable to obtain patient demographics, please obtain a Medical Record Number and face sheet, and then notify your Field Supervisor immediately for guidance.
o If assigned to another call and required to leave the ED prior to synchronization of your EPCR, you must complete the unsynchronized EPCR(s) prior to returning to base.
The Communication Center Staff and Field Supervisors will be monitoring the Synch Status Board to ensure all trips are synchronized prior to your clearing as well as to monitor the time on task.
Monitoring the Synchronization of Patient Care Reports: Communications Center Staff
Communications Center Dispatchers are to monitor the Synch Report to ensure that the designated field units have synchronized their ePCRs prior to the field unit clearing from their transport destination. In the event that a field unit clears and their trip is not synchronized, the dispatcher will give the crew a reminder via the radio system as to the unsynchronized call.
If after the verbal reminder is made to the field crew the trip is still not synchronized, the appropriate division Field Supervisor is to be notified immediately.
Ensuring Compliance: Field Supervisors
In order to ensure compliance with state regulations and company policies, in collaboration with the Communications Center, Field Supervisors will ensure that all EPCR’s are synchronized prior to the field unit clearing from their transport destination.
Field Supervisors may be called upon to assist a field unit in obtaining patient demographics or for a field unit that has not synchronized their EPCR after a verbal reminder from the Dispatchers.
- Unsynchronized Trips – Upon notification from the Communications Center of an unsynchronized trip, the Field Supervisor will contact the Field Unit to offer assistance if needed and to enforce the policy of trip synchronization. This may include collaboration with company’s IT department if needed.
- Unable to obtain Demographics – In the event that a Field Supervisor is contacted by a field unit that they are unable to acquire patient demographics, the Field Supervisor will assist in obtaining the missing information by offering guidance over the telephone or meeting up with the field unit directly to assist. In the event that due to the patients acuity demographics are not readily available, the Field Supervisor will have the field crew obtain a face sheet and Medical Record number and then synchronize their EPCR and will ensure that prior to the end of the Field Supervisors Shift, the demographics will be obtained and scanned into the associated trip in RescueNet.
It is the Field Supervisor’s responsibility to ensure that all trips in their division(s) are synchronized promptly pre-clearing of the facility (or once clear from a subsequent emergency call), to offer guidance when needed and to assist in the collection of patient information as soon as possible and before the end of their scheduled shift.