Patient Care Report (PCR)
Pre-Hospital Emergency Care Council
2005 — commenced in the HSE National Ambulance Service and rolled out nationally over a six-month period.
2006 to 2008 — roll out by voluntary, auxiliary and private licensed Clinical Practice Guidelines (CPG) providers who operate an ambulance.
To facilitate:
- a national framework to record accurate, complete and timely pre-hospital patient data which will provide a vital link in the continuum of patient care in the hospital/destination facility
- robust national clinical audit
- strategic planning
- research into new skill, services/equipment.
2005/2006 (national statutory ambulance services)
2008 (private, auxiliary and voluntary licensed CPG providers who operate an ambulance service).
The Patient Care Report (PCR) is the principal source of patient data collection pre-hospital from time of call receipt by the pre-hospital practitioner to handover of patient at ED/destination facility. In the event of an ambulance service not utilising the Pre-Hospital Emergency Care Council (PHECC) PCR, the PHECC Information standard contains the dataset on which any alternative PCR is designed.
The PCR collects patient demographic data, detailed patient assessment clinical data, medical interventions, medications administered, destination handover data, practitioner and administrative data.
Pre-hospital licensed CPG providers who operate an ambulance service.
Patient information is entered on the two-part PCR in real time for every patient contact.
The PCR must be completed in all circumstances for:
- all emergency calls
- all urgent calls
- all calls where a 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:
A PCR copy is included in handover at the emergency department (ED)/destination facility and stored with the hospital record/chart. The remaining copy is returned to the licensed CPG provider organisation for storage.
Not available.
Information Standard details PCR data set.
Clinical impression, mechanism of injury and incident location terminology are all compliant with International Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM).
Information not available to PHECC as patient records processed and controlled by the licensed CPG provider who operates an ambulance service.
No data published by PHECC as PHECC publishes the standard and related patient report form only. PHECC has no oversight on data collected other than review of clinical audits submitted as a requirement of the annual licensed provider approval process.
Access to data through the individual licensed CPG provider who use the PCR.
No
All PHECC information standards and related patient report forms are reviewed at least every three years to assess compliance with national data collection standards and to assess the care delivered in the pre-hospital environment by practitioners.