Log In

1. User Name: first initial, last name. ex: Smacaluso

2. Password: your chosen password. Log in periodically and remember, passwords expire every 90 days.

3. Agency: GFD (ambulance medics use TRICITY)

* Select Add ePCR incident to add a new report

* Clicking ePCR will give you access to existing reports. A new report can also be generated from that screen

This will bring up your GCS, Revised Trauma Score and Pediatric Trauma Score Charts. These should be entered on patients complaining of pain, traumatic injury, falls, loss of consciousness, head injuries, altered level of consciousness, drug/alcohol intoxication or overdose or anything you feel pertains to this. It is especially important in the event of an improvement, worsening symptoms or any pertinent changes during assessments.

This should be used for any patient complaining of pain. If patient does not or is unable to rate pain, document that and this can be left blank

After you have entered in your treatments, your treatment screen under flow charts will resemble this (obviously, this depends on what, if any, treatments you have done.)

You may chose to click on each one of these individually and fill them out or you can also click the tab on the right titled Assessment Details. You can select No Abnormalities (if applicable) or not assessed on each one. If there is something you found in your assessment that needs to be noted, just click on the white box on the top right of your chosen assessment category.

If you do have something pertinent to note in your assessment section, after you have opened the category, here we chose Extremities, this screen will show up and you need to specify your findings. Make sure anything unfounded gets marked as No Abnormalities.

Here we have that during our assessment the patient was found to have left arm weakness and ‘other’ is selected. If you were to scroll down, you would see a comments section where you would specify any abnormalities found.

At the top of the narrative page, you will see these two sections. Please fill them out accordingly. Remember, if you select Yes patient was injured, you need to complete the other boxes.

Your narrative should be typed under the Narrative section. The section marked Appended Narrative is for addendums.

• Billing and Signatures tab are typically for transported patients. However, patients that are treated and released, like a diabetic patient, need to have that documented here. There are multiple options. Transported patients also have loaded miles documented here.

• Signatures are obtained by the transporting crew using their laptops. If unable to use laptop, paper copies are available for signatures.

1. Your almost done, just a few more steps! Make sure to validate every report once completed. Click the green check mark at the top of the page and follow the prompts to continue with validation.

2. Once the ‘Confirm’ box shows up, select OK.

3. A second confirmation box will appear, click OK

** Important Note: Once you have clicked the check mark, if you have anything incomplete, it will prompt you and will not let you continue until it is done. Make sure all of your necessary and pertinent information is filled in ALL fields. Once you validate you cannot changes. If something needs to be changed, you will need to document in the Appended Narrative section what needs to be added, removed or otherwise changed and why. The program will time and date stamp any changes made.

1. Only one copy is needed for releases and transfer of care reports to be filed with NFIRS. If patient is transported, the ambulance crew will print two of their reports, one to leave at ER and one for FD filing and will be attached with NFIRS report.

2. To print, just click the icon that looks like a printer at the top right.

3. You will then see a screen prompting you to select which type of report to print. For a transfer of care report or release obtained by engine companies, choose the Patient Care Report. (Billing PCR is used for transporting ambulances) The Refusal option is when the ambulance personnel obtains a refusal using their laptops.

Printing Reports

After you have selected your print option, you will see a print preview screen similar to this. Please note how this example says Draft at the top. Your report is incomplete if it says draft.You’ll need to exit preview screen and make sure your report has been validated and locked.

Once it’s appropriately validated, you won’t see the Draft indicator, click the printer icon on your top left and it will be printed.

• EMT-B’s and Paramedics both can obtain a basic release/MPR. Release should be obtained on all EMS related calls when patients are not being transported.

• Minor patients cab be released BUT Delnor must be contacted and guardian should be on scene to sign release. OLMC may allow release if parent/guardian has been spoken to over the phone.

* Important definitions/description per SFVEMSS protocol:

Refusals: Patients who are judged to be legally and mentally decisional have the right to refuse any and all treatment. Patients who are non-decisional may not consent to or refuse treatment.

Minors: Patients who are minors (<18) should have consent of a parent or guardian obtained prior to treatment unless they qualify as an emancipated minor or qualify for care under implied consent under the Emergency Doctrine. See System-specific policies regarding notification of parent or guardian if they are not immediately available.

Physicians on scene: May offer their services and direct patient care only when an Illinois M.D. or D.O. physician’s license is shown. The physician must accompany the patient to the hospital. OLMC must be contacted immediately and the scene physician shall discuss the case with the ED physician. EMS personnel must not exceed their scope of practice to comply with the requests of an on-scene physician.

Consent: Decisional adults must consent to treatment. Consent must be informed or clearly implied via verbal agreement to the treatment or gestures indicating their desire for treatment. A patient's lack of refusal or physical resistance or withdrawal will be taken as consent.

Consent (Implied): Patients who are unconscious or otherwise so incapacitated that they cannot comply with the above provisions and do not exhibit the ability to make sound judgments, will be treated under implied consent. Patients who are obviously impaired with altered judgment who are unable to understand their decisions, have slurred speech, and/or ataxia; those suffering from mental illness; those who have made suicidal/homicidal statements (to EMS personnel or persons physically present at the scene who will attest to the statements on a petition form) are to betreated under the doctrine of implied consent. They are not allowed to refuse treatment or transport.

Abandonment: No patient with continuing medical needs shall be abandoned. Abandonment includes executing an inappropriate refusal, releasing a patient to a less qualified individual or discontinuing needed medical monitoring before patient care is assumed by other professionals of equal or greater licensure than the level of care required by the patient.

Multiple Release (MPR)

- MPR’s are used in situations where 2 or more patients are found and they do not require or request any further medical treatment/transport and have no complaints. However, if for example you go to a MVC with 5 patients and 4 are uninjured and have no complaints, but one patient does have a complaint, that one patient needs an individual release, the rest can go on an MPR. This is per SFVEMSS.

- Pt’s must be 16 y/o or older. (Minor patients still require that Delnor be contacted.)

- When obtaining your information, please remember to get a date of birth (the form only asks age).

- If incident is a MVC, please try to note in comments location and extent vehicle damage, airbag deployment, if patient was restrained etc.

- Sign the bottom and have your partner or other person sign as well.

Uses:1. For patients that treatment/transport is recommended

and they refuse treatment/transport. 2. Patients not requiring/requesting emergency

transport/treatment.3. Patients refusing specific treatments. Please check all that

apply or add in the specified area. 4. Patients refusing recommended transport to closest

hospital. 5. MD’s assuming care and accompanying pt. during

transport. * Remember to obtain and document vitals (per sfvemss)* All minor age releases must be called in to Delnor prior to releasing and guardian should be on scene to sign. * Ideally, try to get a witness signature from family, friends, persons remaining with patient etc. If unable, use PD, FD or other EMS personnel. * If patient refuses to sign refusal, complete bottom portion. Patient/guardian must print on the top line, initial appropriate option and sign at the signature line towards the bottom.

Individual Release

Pt prints name

Patient or guardian should initial all that apply.

Pt’s or pt representative signature