Which of the following is the PRIMARY purpose of the Patient Care Report (PCR)?

Continuity of patient care between providers. While the PCR serves many functions including legal protection, billing, and QI, its primary purpose is continuity of care. The PCR communicates critical patient information from the prehospital setting to the receiving facility, ensuring seamless care transitions.

An EMT discovers an error on a handwritten Patient Care Report. What is the correct way to correct it?

Draw a single line through the error, initial it, and write the correction. The proper way to correct an error on a paper PCR is to draw a single line through the error (so the original entry is still legible), initial it, and write the correct information nearby. Never use correction fluid, erase, or discard documentation.

What does the "B" in the SBAR communication format stand for?

Background. SBAR stands for Situation, Background, Assessment, and Recommendation. The "B" (Background) is where you provide the patient's relevant history, including age, sex, chief complaint, and pertinent medical history.

Under HIPAA, which of the following is considered Protected Health Information (PHI)?

A patient's name linked to their medical condition. PHI is any individually identifiable health information. A patient's name linked to a medical condition is PHI and is protected under HIPAA. De-identified data and aggregate statistics are not considered PHI.

During transfer of care at the hospital, the EMT should:

Provide a verbal face-to-face report to the receiving provider. Transfer of care requires a face-to-face verbal report to the receiving nurse or physician. The EMT must ensure the receiving provider acknowledges the handoff. Simply leaving paperwork or radioing a report does not constitute proper transfer of care.

5.2 Documentation & Communication | NREMT EMT Certification | Free Exam Prep

Key Takeaways

The Patient Care Report (PCR) is a legal document that serves as the official record of the EMS encounter and must be completed for every patient contact
The minimum data set includes patient demographics, chief complaint, vital signs, assessment findings, treatments provided, and times
Radio communications should follow the format: identify yourself, identify who you are calling, keep transmissions brief and clear, and use plain English (avoid codes unless local protocol requires them)
SBAR (Situation, Background, Assessment, Recommendation) is the standard format for hospital notification and structured handoff communication
Transfer of care requires a verbal handoff report to the receiving provider and should never occur to a provider with a lower level of certification
HIPAA requires that patient information be shared only with those who have a legitimate need to know for continuity of care or as required by law
Accurate documentation protects the EMT legally, ensures continuity of care, supports quality improvement, and is required for billing

Patient Care Report (PCR)

The Patient Care Report (also called the prehospital care report or run report) is the official written record of the EMS call. It is a legal document and serves multiple purposes:

Continuity of care -- Communicates patient information to the receiving facility
Legal record -- Protects both the patient and the provider in legal proceedings
Quality improvement -- Used for system-wide data analysis and performance review
Billing and reimbursement -- Required for insurance and Medicare/Medicaid claims
Research and education -- Contributes to EMS data and training materials

Essential PCR Components

Component	Details to Document
Patient information	Name, age, sex, date of birth, address, weight
Chief complaint	Patient's own words in quotes when possible
History (SAMPLE/OPQRST)	Signs/symptoms, allergies, medications, past history, last oral intake, events
Vital signs	At least two sets; include time of each measurement
Physical exam findings	Head-to-toe or focused exam results
Assessment/impression	EMT's field impression based on findings
Interventions/treatment	Every treatment provided with times and patient response
Times	Dispatch, en route, on scene, patient contact, transport, arrival at facility
Narrative	Detailed chronological account of the call
Disposition	Where the patient was transported or if they refused care

Minimum Data Set

The minimum data set is the baseline information that must be collected on every patient encounter:

Patient Data:

Chief complaint
Level of consciousness (AVPU)
Systolic blood pressure (patients >3 years old)
Skin perfusion (capillary refill for patients <6 years)
Skin color and temperature
Pulse rate
Respiratory rate and effort

Administrative Data:

Date and time of the incident
Time of dispatch, en route, on scene, transport, and arrival
Unit and crew identification
Patient disposition

Documentation Best Practices

Document objectively -- record what you see, hear, and measure
Use quotes for patient statements: Patient states, "My chest hurts"
Avoid subjective terms like "appears intoxicated" -- instead describe observed signs
Document refusals thoroughly with competency assessment and risks explained
If an error is made on a paper form, draw a single line through it, initial, and write the correction
Never alter or falsify a PCR -- this is a legal and ethical violation
Late entries should be clearly labeled with the date and time they were added

Radio Communication

General Principles

Press the button, wait 1 second, then speak (avoids clipping the first word)
Speak clearly and at a moderate pace
Keep transmissions brief -- the radio channel is shared
Use plain English unless local protocol specifies codes
Do not transmit patient names over the radio (HIPAA)
Confirm receipt of orders by repeating them back

Hospital Notification Format (SBAR)

Element	Content	Example
S -- Situation	Who you are, unit number, ETA	"Medic 7 to General Hospital, 8-minute ETA"
B -- Background	Patient age, sex, chief complaint, history	"65-year-old male, chest pain for 30 minutes, history of MI"
A -- Assessment	Vital signs, exam findings, interventions	"BP 160/90, HR 88, RR 20, 12-lead shows ST elevation in II, III, aVF. Aspirin administered."
R -- Recommendation	What you need from the hospital	"Requesting STEMI activation"

Transfer of Care

Transfer of care occurs when you hand off patient responsibility to the receiving facility or provider:

Provide a face-to-face verbal report to the receiving nurse or physician
Include all pertinent findings, treatments, and changes during transport
Ensure the receiving provider acknowledges the handoff
Never transfer care to someone with a lower certification level
Leave a copy of the PCR with the receiving facility
Transfer of care is not complete until the receiving provider accepts responsibility

HIPAA Considerations

HIPAA (Health Insurance Portability and Accountability Act) governs the privacy and security of patient health information:

Protected Health Information (PHI) includes any information that can identify a patient: name, date of birth, address, Social Security number, medical records
PHI may be shared for treatment, payment, and healthcare operations without specific patient consent
Do NOT discuss patient information with people who do not have a need to know
Do NOT post patient information or images on social media
Radio transmissions should avoid using patient names
Report any suspected HIPAA breaches immediately

NREMT EMT Certification

1Introduction: NREMT EMT Exam Overview

2Chapter 1: Airway, Respiration & Ventilation

3Chapter 2: Cardiology & Resuscitation

4Chapter 3: Trauma

5Chapter 4: Medical, OB/GYN & Special Populations

6Chapter 5: EMS Operations