Unit Training Information Management Objectives By the end of this session you should be able to: • Populate all the required information on a CFRR/ACR/PTR/PCR in accordance with PHECC completion guidelines. • Request a unique incident call number (INCO)for transporting a patient in a Red Cross vehicle. Which Report do you use? • A Cardiac First Responder Report (CFRR) is used if you have attended a Cardiac arrest as part of a CFR in the community group. • An Ambulatory Care Report (ACR) is used for the general treatment and discharge of a patient back to an event, that the Irish Red Cross is covering. • A Patient Transport Report (PTR) is used for the Inter facility transport of a patient that has no interventions. • A Patient Care Report (PCR) is used if a patient is to be transported to an Emergency Department, there may also be an ACR completed but a PCR must also be completed for the transport. Purpose of PCR/ACR/CFRR • Clinical – Recording pre-hospital care interventions and medications administered is an essential clinical responsibility of pre-hospital emergency care practitioners. – Documents the events preceding and possible hospital admission of the patient (ref PCR). Purpose of PCR/ACR/CFRR • Legal – Patient Care Report’s identify the care that has been given to a patient. – Properly completed it will give protection and be an essential aid if called as a witness in court. Purpose of PCR/PTR/ACR/CFRR Organisation Information – Activity related information can assist in future planning and development. – May be used for Public Health monitoring and to provide information for research into new skills, services, equipment and other resources required in the future. – Assist in the development of both service and individual training plans. Purpose of PCR/ACR/CFRR Inaccurate documentation is potentially damaging to patients, the IRC (Service Provider) and the standing of the prehospital emergency care practitioner. CFR Report Ambulatory Care Report Patient Care Report edition 3 Patient Care Report edition 3 OHCAR • The Out of Hospital Cardiac Arrest Register is a National Register that will assist in better understanding of the causes and interventions in cardiac arrest. • Please ensure if you have attended a Cardiac Arrest that the OHCAR section on the back of the PCR is completed with the most information that can be obtained Patient Transport Report Entering Information on Forms • Accurate • In real time if possible • Factual • Complete • Legible • Correct • • • • • • • Objective Errors Signing – PIN Tick Box Coded Entry Abbreviations Numerical See www.phecit.ie for more information on form completion Requesting an INCO number 1. To request an INCO number text 087-2873955 with INCO 1234 • • No commas or apostrophes. Insert one blank space between INCO and your PHECC number. Inputting an INCO number 1. 2. 3. You will receive back, by text your INCO incident number. Record this number in the Incident Number field box on the Incident Information page of the PCR. Record your PHECC PIN in the correct Attending or Supporting field boxes. Communications Centre Codes 1. Communications codes are to be entered into the CC code field box on the PCR. 2. The code that is used is the region that the incident has occurred in. Communications Centre Codes Communication Centre Irish Red Cross Region CC30 IRC Head Office CC31 Dublin North East CC32 Dublin Mid Leinster CC33 Southern CC34 Western CC35 Commercial Services Department CC36 Spare CC37 Spare CC38 Spare CC39 Irish Red Cross Search and Rescue (2 MRT’s and 1 Lifeboat) Station Code Station Code IRC Area Station Code IRC Area CA Carlow LC Limerick CB Cavan LD Longford CL Clare LA Louth CE Connemara MA Mayo CR Cork MC Meath DE Donegal MB Monaghan DB Dublin Borough O Offaly DC Dublin Fingal S Sligo DA South Co. Dublin LE Leitrim DD Dun Laoghaire/Rathdown R Roscommon G Galway T Tipperary KC Kerry WA Waterford KA Kildare WD Westmeath KL Kilkenny WB Wexford LB Laois WC Wicklow RC Head Office SA/SB Spare Handover Report • • • • • Provide age and gender of patient. Describe incident and chief complaint. Describe patient’s level of responsiveness. Report vital signs and examination results. Report pertinent medical condition in SAMPLE format. • Report interventions provided. • Hand over top copy (original) of PCR. Summary • Purpose of Patient Care Report completion. • Information entry onto CFRR/PTR/ ACR/PCR. • Handover Report. References • Irish Red Cross SOP’s Patient Care Reporting ver. 1.3 • PHECC STN003-PCR Information Standard ver. 2.0 • 3rd Edition PCR Completion guide (AudioVisual) • Ambulatory Care Report Guidebook • CFR Report Completion Guide • PHECC Glossary of terms ver.1.0 • All PHECC documents can be downloaded or viewed from www.phecit.ie