THE IMPORTANCE OF COMPLETE PCR’S and EMS REPORTS FOR EVERY RESPONSE

THE IMPORTANCE OF COMPLETE PCR’S and EMS REPORTS FOR EVERY RESPONSE

By Jennifer Coalson-Perez, Executive Director, EMS Guardian

Kern County Firefighter Graham Mitchell had his EMT-P license suspended for 90 days and was placed on probation for a term of three years for several allegations: one of which was a failure to thoroughly complete Patient Care Records (PCR) for a diabetic patient, and another was failure to complete any PCR for a snake bite victim that showed up at the station and then left with her parents for the hospital.

The diabetic was someone Mitchell had responded to and treated on many occasions and he had always refused transport.  In the PCR, Mitchell failed to note the man’s glucose levels and a few vital signs.  The 14 year old snake bite victim had arrived at the station with her parents and they refused transport after realizing there was no anti-venom on hand.  They made the decision that it would be faster to drive themselves to the nearest hospital, and as a result Graham did not create a PCR.

Neither occurrence resulted in any form of patient harm. The diabetic was perfectly fine after being treated and as usual, signed a release refusing transport.  The 14 year old and her parents made it to the hospital and she was treated and released without any further complications. So why was Graham disciplined by the EMS Authority?

While the state does not regulate PCR’s directly by mandating specific PCR procedures and requirements, the local city or county that offer the EMS services does.  It is not uncommon for multiple layers of policy or procedure to exist, any of which (when violated) can become a basis for investigation and/or discipline by the State.  Los Angeles’ policy on PCR’s is as follows:

Los Angeles Policy Regarding Pre-Hospital Patient Care Documentation Standards

The EMS Report must:

1. Contain all grey shaded data fields and all appropriate black sections
2. Be completed for all patient contracts and each 9-1-1 call, including:

• Transported patients
• Non-transports
• No patient found
• Cancelled calls
• DOA Calls

1. For pre-hospital births, a separate PCR must be completed for the mother and each newborn
2. Be completed immediately after each call when possible, and prior to going off duty
3. A copy must be provided to the receiving hospital prior to leaving the facility unless the unit is needed for another emergency call, in which case it will be provided prior to going off duty, or within 24 hours, whichever is earlier.
4. Be completed for all patients during MCI.  Patient tracking information will be included on the PCR. MCI Base Hospital Forms can be used for 3 or more patients

Had Mitchell been a Local 112 Firefighter and failed to complete a PCR in its entirety (or failed to complete a PCR for a patient that he didn’t even really treat), his EMT-P license would have been similarly suspended and disciplined based on the following grounds:

EMSA  Policies Regarding the Disciplinary Process for Pre-hospital Personnel

1. The state EMS Authority may deny, suspend, or revoke any EMT-P license, or may place any EMT-P license or license holder on probation upon the finding by the Director of the State EMS Authority of any of the following actions, which shall be considered evidence of a threat to the public health and safety:
• “violating or attempting to violate directly or indirectly, or assisting in or abetting the violation of, or conspiring to violate, any provision of this division or the regulations adopted by the authority pertaining to pre-hospital personnel”
• If the Medical Director of the EMS Agency sends a recommendation to the State EMS Authority for further investigation or discipline of the license holder… in deciding what level of disciplinary action is appropriate in the case, the Authority shall consult with the Medical Director of the EMS Agency.
2. Temporary Suspension
• After consultation with the relevant employer, the director of the State EMS Authority or the Medical Director of the EMS Agency, may temporarily suspend, prior to hearing, any EMT-P license upon a determination that:

• The licensee has engaged in acts or omissions that constitute grounds for revocation of the license, or
• Permitting the licensee to continue to engage in licensed activity, or without restriction, would present an imminent threat to the public health or safety.

It was established that Mitchell violated county protocols when treating patients and not completely or accurately documenting said treatment on a PCR.  This constituted a violation of section 1798.200, subdivisions (c )(7) and (c)( 10). Therefore, his license was subject to discipline by the EMSA.

License disciplines are rarely the result of an overt act of incompetence, negligence, fraud, or violations of statute.  Most “crimes” resulting in license discipline are the result of infrequent and unwise decisions, like a DUI or domestic violence. But keep in mind it is the little “it slipped my mind” and “I didn’t have time” issues that land you in trouble with your LEMSA and eventually the State as well.  It may seem like such a minor detail, but when the political bureaucracy that is the EMSA focuses its sights on you, it will become the most important issue in the world.  Make sure to dot your “I”s cross your “t”s and fill out all 67 fields of the PCR, every single time.   Your livelihood, career and way of life depend on it!