PHECC - Patient Care Report (PCR)

Source: 
National Data Collection
Managing Organisation: 
Pre-Hospital Emergency Care Council (PHECC)
Contributor: 

Pre-hospital emergency care providers/national ambulance service practitioners

Subject: 

PHL terms: EMERGENCY CARE, AMBULANCE, PATIENT, PRE-HOSPITAL, PRACTITIONER

Description/Summary: 

The Patient Care Report (PCR) facilitates the collection of patient pre-hospital data by the practitioner from time of call to handover of patient to destination facility. The information is collected by statutory ambulance services, auxiliary and voluntary services and private ambulance service providers. Paper-based collection of patient data using the national PCR was commenced in the HSE ambulance service in July 2005 and was further rolled out nationally over a six month period. A pilot of electronic data capture commenced in October 2007 in HSE North East ambulance region; in 2008 in Belmullet ambulance station and further national since 2010.

The data is collected real time at point of care whether paper or electronic system. Currently the paper-based data is accessed only by the ambulance service or by them on behalf of a third party. This data is used for strategic planning of the ambulance service, informs research into new skill, services/equipment. It can also assist in development of both service and individual training plans for the practitioners. The data is also used for clinical audit.

The objective of the PCR is to facilitate a national framework to record accurate, robust and timely pre-hospital patient data which will provide a vital link in the continuum of patient care in the hospital/destination facility. The PCR provides vital clinical audit information for research into new skills, services, equipment and other resources required in the future.

Statement of Purpose: 

To facilitate a national framework to record accurate, robust and timely pre-hospital patient data which will provide a vital link in the continuum of patient care in the hospital/destination facility.

Coverage: 
National from mid 2010.
Method of data collection: 

Patient information is entered on the paper PCR in real time.

PCRs must be completed in all circumstances listed:

  • All emergency calls
  • All urgent calls
  • All calls where an practitioner has to treat a patient
  • All calls involving refusal of treatment and or transport contrary to the advice given by the practitioner
  • All calls where patient is treated at scene and not transported

Paper-based system:

During handover at the Emergency Department (ED) in the hospital the top copy of the form is stored with the patient’s hospital record/chart. The bottom copy is returned to the ambulance station where stored.

Electronic process (piloted in a number of areas – see description above):

The ambulance control centre collects patient data in response to calls from the public and the information is integrated with the electronic PCR system on tablet PCs in the ambulance. The auxiliary, voluntary and some private ambulance service providers also collect pre-hospital patient data. Shortly these providers will enter the information into a desktop version of the electronic PCR. This desk top version will be located in ten individual organisations headquarters only.

Data content: 

Includes the following: patient care report number; demographic data; ambulance region communications centre code; call data; incident information; patient’s chief complaint; clinical impression; allergies; medications; past medical history; event details; vital observations; care management data; journey data; patient assessment; clinical status

Data dictionary: 

Guidebook for PCR and dataset definitions published on PHECC website

Clinical Coding Scheme: 
ICD 10-AM in the background for all fields possible
Accessing data: 

Paper: The PCR data is accessed by retrieving the relevant paper records from storage in the individual ambulance headquarters of which there are 9 nationally including Dublin Fire Brigade. HSE Midlands scan all of their PCRs and they are stored on an electronic system in HSE Midlands ambulance headquarters.

Electronic data:

  • via electronic viewing module called e-Triage ED at destination EDs to which the patient is being transported,
  • via electronic viewing module called e-Triage Station where practitioners/ambulance service managers have access to view the patient data,
  • via Reporting Module for access to aggregated data by ambulance service management and PHECC (Pre-Hospital Emergency Care Council).

Access to identifiable data as follows: Assistant National Director of the Ambulance Service, Chief Ambulance Officers in the various HSE regions, Deputy Chief Ambulance Officers and Training Officers and Dublin Fire Brigade Management.

Access to de-identified data: all practitioners have access to the patient de-identified record of the patient they administered care to and transported. The Auxiliary and Voluntary organisations access PCR data by retrieving their paper records from storage in their individual organisations headquarters.

Date collection commenced: 
Paper collection of patient data using the national Patient Care Report was commenced in the HSE ambulance service in July 2005 and was further rolled out nationally over a six month period. A pilot of electronic data capture commenced in October 2007 in HSE North East ambulance region/2008 in Belmullet ambulance station and national since 2010.
Published information/Update frequency: 
Data collected each time a patient is treated and transported by the ambulance service. Data not published.
Generic email contact: 
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