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The aim of this audio-visual presentation is to provide clear guidance for the accurate completion of the patient care report recording prehospital care interventions and medications administered to patients is an essential clinical responsibility of all prehospital emergency care practitioners every responder and practitioner must provide clear accurate and comprehensive patient care information the PCR is a two-part pocket-sized report comprising 10 colored panels and folded in such a way that the written information flows easily from panel to panel without having to open it out on the Okapi the following is recorded incident information patient demographic information clinical information vital observations' medication treatment care management continuity of care clinical audit emergency department handover signature and additional information the second copy has four additional panels on the back for use by the practitioner to record the following out of hospital cardiac arrest declined treatment and/or transport and additional information PC ORS must be completed in the following circumstances all emergency calls all urgent calls all calls were a practitioner has to treat a patient all calls involving declined treatment and/or transport all calls where a patient is treated at the scene but not transported the PC or must be completed in real-time are as close to the event as possible the PC or identifies the care that has been provided by you and if not completed soon after the event may lack accuracy due to difficulties in recall however in cases of major trauma our immediate critical care patient care will always take precedent over full completion of the PC or a properly completed PC or will give protection to you and will be an essential aid if called in court as a witness remember one golden rule of documentation if it isn't written down it didn't happen the information on the PC or can be divided into two principal categories one relates to the health of the patient and the other relates to you and the activities of your organization it is vital that each Presley or provides as much reliable information as possible the usefulness of the information directly reflects the level of completeness and accuracy of the data captured entering information comprises free text and tick boxes entered the panels incident information the date of the call is the day on which the call is received by the communication center when entering time always use the 24-hour clock there are a number of key times to be entered in this section which are principally used for the collection and measurement of response time details dispatch classification reference a dispatched classification reference would be provided by the communication center when a call is processed using the medical dispatch priority system for example nine echo one suffix a will be entered as follows priority response is a response given to you by the communication center this is in line with...
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