West Virginia Office of Emergency Medical Services

Excerpt from WV OEMS Patient Care Record Instructions :

Introduction

The instructions on the following pages are designed to assist EMS Personnel in completing the West Virginia Office of Emergency Medical Services Patient Care Record (PCR). It is imperative that EMS personnel complete the form in its entirety. It is strongly recommended that your agency provide annual inservice training on the proper completion of the PCR for all personnel and that this inservice training become a part of your orientation process for new staff. The staff of your West Virginia Emergency Medical Services Technical Support Network (TSN) Field Office can assist you in developing and delivering the inservice program.

The PCR is a multi-purpose document. First and foremost, the PCR is a medical patient record. As such, accuracy and completion are essential since the form will be utilized by the hospital's medical staff as a source document for developing a patient history and become a part of the patient's permanent medical record.

The form is also a data collection mechanism for the Regional and State EMS System. Many of the statistics quoted in State and National reports regarding injuries and medical emergencies in West Virginia, as well as the local, Regional, and State EMS Systems' response capabilities for those patients, are derived directly from the PCR forms submitted to TSN.

Although billing procedures vary, many EMS agencies utilize the PCR as the sole source of obtaining necessary billing information. Failure to accurately complete the entire form could result in either diminished reimbursements or rejection of claims by third party payors such as Medicaid, Medicare and private insurance agencies. The resulting loss of revenue could be the difference in whether or not your agency is able to remain financially solvent.

Finally, the PCR is a primary tool for Prehospital Care Quality Improvement Programs. Accurate completion of the form allows the agency's physician medical director and other individuals responsible for quality improvement to analyze your agency's response to various types of situations. It also provides a mechanism to document improvements in that response resulting from changes in procedure or protocol.

Read the full PCR instruction manual in pdf or read the manual appendices, revised 10/07/05 .