Data Collection
Pursuant to the Rules & Regulations promulgating the EMS System Act of Pennsylvania, "§ 1021.41. EMS agencies shall collect, maintain and electronically report complete, accurate and reliable patient data and other information as solicited on the EMS PCR form for calls for assistance in the format prescribed by the Department. An EMS agency shall file the report for calls to which it responds that result in EMS being provided. The report shall be made by completing an EMS PCR within the time prescribed by the EMS agency’s written policies, no later than 72 hours after the EMS agency concludes patient care, and then submitting it, within 30 days, to the regional EMS council that is assigned responsibilities for the region in which the EMS agency is licensed.”
Below are some answers to commonly asked questions related to Data Collection:
I'm a BLS Service, must I forward a copy of the tripsheet (patient care report) to the receiving facility, even if ALS is on board?
"The EMS agency shall provide the completed EMS PCR to the receiving facility to which the patient was transported within 72 hoursafter the EMS agency concluded patient care."
- Williamsport Hospital & Medical Center - 570-321-2265 (Please note this is a NEW #)
- Muncy Valley Hospital - 570-546-4138
- Jersey Shore Hospital - 570-398-1850
- Soldiers & Sailors Memorial Hospital - 570-724-6541
- Evangelical Community Hospital - 570-522-4740
- Geisinger Medical Center - 570-271-7165 (Please note corrected #) Can also email to secure address: PCRTRAUMA@geisinger.edu
- Bloomsburg Hospital - 570-387-2245
- Memorial Hospital (Towanda) - 570-268-2244
- Robert Packer Hospital - 570-887-4939
- Troy Hospital - 570-297-3106
- Lock Haven Hospital - 570-893-5023
This is required of all EMS Agencies completing a patient care report, ALS, BLS, or Helicopter. The tripsheet then becomes a part of a patient's permanent medical record.
What if a helicopter transports my patient?
The same requirement exists to provide a copy of the tripsheet to the facility who ultimately receives your patient. Below are the fax numbers to the most frequently utilized aircraft by LTS Providers:
-
- Geisinger Medical Center (LifeFlight) - 570-271-7165 (Affiliate #47700)
- Robert Packer Hospital (Guthrie Air) - 570-882-4939 (Affiliate #08013)
- Hershey Medical Center (LifeLion) - 717-531-3878 (Affiliate#22091)
How long must I keep copies of patient care reports?
"The ambulance service shall retain a copy of the EMS patient care report for a minimum of 7 years."
The Pennsylvania Department of Health distributes a list of approve data collection vendors (revised 7/2015). Tripsheets must be completed on forms provided by the Department of Health through the Regional EMS Councils or on DOH approved programs.
As a CQI coordinator for my service I notice that documentation on patient care reports could be improved. Any hints??
Click HERE for some guidlines on documenting patient care on the tripsheet.
The LTS EMS Council staff is also available to provide on-site support for documentation. Please contact the council to schedule a training session. Invite your neighboring companies! Con.ed. credit may be available.
What must be included in a Patient Refusal??
A complete patient assessment should be completed on all patients who wish to refuse treatment/transport. The LTS EMS Council provides Patient Refusal forms free of charge for all services in Lycoming, Tioga, and Sullivan Counties. Form should be completed on all patients refusing treatment and signed by the patient. Remember, medical command should be contacted in certain circumstances (outlined on the form) and in those cases where patients may wish to refuse and the EMS Crew does not believe it is in the patient's best interest to do so, you can have medical command speak directly to the patient. (See PA Protocol #111 - Refusal of Treatment/Transport.)
| |
|
|
Common Medical Abbreviations for Tripsheets
|
| ABBREVIATION |
MEANING |
| ABG |
Arterial blood gas |
| A* |
Before |
| a.c. |
Before meals |
| ADL |
Activities of daily living |
| ad lib |
As desired |
| Afib |
Atrial fibrillation |
| AFL |
Atrial flutter |
| AIDS |
Acquired immunodeficiency syndrome |
| AP |
Anteroposterior |
| A&P |
Anterior and posterior |
| AQ |
Water |
| ARDS |
Adult respiratory distress syndrome |
| ASHD |
Atherosclerotic heart disease |
| b.i.d. |
Twice a day |
| BLS |
Basic life support |
| BP |
Blood pressure |
| bpm |
Beats per minute |
| BUN |
Blood urea nitrogen |
| BX, Bx |
Biopsy |
| C |
Celsius, centigrade, complement |
| c* |
With |
| Ca |
Calcium |
| CA, Ca, ca |
Cancer, carcinoma |
| CAB |
Coronary artery bypass |
| CAD |
Coronary artery disease |
| caps |
Capsules |
| CBC |
Complete blood count |
| CC, C.C. |
Chief complaint |
| cc |
Cubic centimeter |
| CCU |
Coronary care unit |
| CHF |
Congestive heart failure |
| CK |
Creatine kinase |
| Cl |
Chloride, chlorine |
| cm |
Centimeter |
| CNS |
Central nervous system |
| CO |
Carbon monoxide, cardiac output |
| CO2 |
Carbon dioxide |
| COMP |
Compound |
| COPD |
Chronic obstructive pulmonary disease |
| CPK |
Creatine phosphokinase |
| CPR |
Cardiopulmonary resuscitation |
| CSF |
Cerebrospinal fluid |
| CVA |
Cerebrovascular accident |
| D&C |
Dilatation and curettage |
| DM |
Diabetes mellitus |
| DNA |
Deoxyribonucleic acid |
| DO |
Doctor of osteopathy |
| DX, Dx, dx |
Diagnosis |
| ECG |
Electrocardiogram |
| ED |
Emergency department |
| EEG |
Electroencephalogram |
| ENT |
Ear, nose, and throat |
F |
Fahrenheit |
| ft |
Foot, feet, (measure) |
| g, gm |
Gram |
| GI |
Gastrointestinal |
| GP |
General practitioner |
| gt, gtt |
Drop, drops |
| GU |
Genitourinary |
| GYN, gyn |
Gynecology |
| Hb |
Hemoglobin |
| HCT |
Hematocrit |
| Hg |
Mercury |
| Hgb |
Hemoglobin |
| HGH |
Human growth hormone |
| HI |
Hemagglutination inhibition |
| HLA |
Human leukocyte antigen |
| HR |
Heart rate |
| Hr |
Hour |
| h.s. |
At bedtime, hour of sleep |
| Hx |
History |
| Hz |
Hertz (cycles per second) |
| IABP |
Intra-aortic balloon pump |
| ICF |
Intracellular fluid |
| ICU |
Intensive care unit |
| I.M. |
Intramuscular |
| I.V. |
Intravenous |
| IVP |
Intravenous pyelogram |
| K |
Potassium |
| kg |
kilogram |
| LAD |
Left anterior descending (coronary artery) |
| lb |
Pound |
| LBBB |
Left bundle branch block |
| LDL |
Low-density lopoprotein |
| LUQ |
Left upper quadrant |
| MD |
Medical doctor, muscular dystrophy |
| mEq |
Millequivalent |
| Mg |
Magnesium |
| mg |
Milligram |
| MI |
Myocardial infarction |
| ml |
Milliliter |
| mm |
Millimeter |
| MRI |
Magnetic resonance imaging |
| MS |
Multiple sclerosis, morphine sulfate |
| N |
Nitrogen, normal (strength of solution) |
| Na |
Sodium |
| NaCl |
Sodium chloride |
| NGT |
Nasogastric tube |
| NPO |
Nothing by mouth |
| Ob-GYN |
Obstetrics and gynecology |
| OTC |
Over the counter (a drug that can be obtained without a prescription) |
| oz |
Ounce |
| PaCO2 |
Partial pressure of carbon dioxide in arterial blood |
| PaO2 |
Partial pressure of oxygen in arterial blood |
| p.c. |
After meals |
| PCO2 |
Partial pressure of carbon dioxide |
| PO2 |
Partial pressure of oxygen |
| peds |
Pediatrics |
| PERRL |
Puplis equal, round, react to ligh |
| PID |
Pelvic inflammatory disease |
| PKU |
Phenylketonuria |
| PMS |
Premenstrual syndrome |
| P.O. |
By mouth |
| PPD |
Purified protein derivative (of tuberculin) |
| ppm |
Parts per million |
| p.r.n. |
As needed, whenever necessary |
| psi |
Pounds per square inch |
| PT |
Physical therapy |
| PVC |
Premature ventricular contraction |
| q |
Every |
| q.d. |
Every day |
| q.h. |
Every hour |
| q2h |
Every 2 hours |
| q4h |
Every 4 hours |
| q.i.d. |
Four times a day |
| RLQ |
Right lower quadrant |
| RN |
Registered nurse |
| RNA |
Ribonucleic acid |
| R/O |
Rule out |
| ROM |
Range of motion (of joint) |
| RUQ |
Right uper quadrant |
| Rx |
Prescription |
| s* |
Without |
| SaO2 |
Systemic arterial oxygen saturation (%) |
| S.C., SQ, subq |
Subcutaneous |
| SIDS |
Sudden infant death syndrome |
| SOB |
Short of breath |
| S&S |
Signs and symptoms |
| ss* |
One-half |
| stat |
Immediately |
| STD |
Sexually transmitted disease |
| Tabs |
Tablets |
| TB |
Tuberculosis |
| temp. |
Temperature |
| TIA |
Transient ischemic attach |
| t.i.d. |
Three times a day |
| TMJ |
Temporomandibular joint |
| TPR |
Temperature, pulse, respirations |
| tsp |
Teaspoon |
| UA |
Urinalysis |
| URI |
Upper respiratory infection |
| Vfib |
Ventricular fibrillation |
| VS |
Vital signs |
| VT |
Ventricular tachycardia |
| UTI |
Urinary tract infection |
| WBC |
White blood cell |
| |
|
* abbreviations should have a line above the character or abbreviation
|
| For more information contact: |
| |
| Name: |
|
| Title: |
Regional EMS Field Coordinator |
| Office: |
LTS EMS Council |
| Email: |
|
| Voice: |
570-433-4461 |
| Fax: |
570-433-4435 FAX |