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Knowledge Center

Completing an ePCR - Assessment

Purpose Statement

The Assessments section of the First Due Electronic Patient Care Report (ePCR) allows EMS personnel to document patient complaints, assessment findings, cardiac arrest information, stroke-related information, and injury details.

This section helps responders maintain accurate and comprehensive patient care documentation by organizing clinical findings and incident-related information within a single report.

Background Information

The Assessments section is located within the ePCR incident report under Incident Documentation.

Users can access this section when creating a new EMS incident or editing an existing EMS chart.

The Assessments section contains six tabs:

  • Situation: Document incident circumstances, including injury, work-related incidents, alcohol use indicators, mass casualty events, and triage classification.
  • Impressions: Record primary and secondary patient complaints, associated symptoms, and assessment findings.
  • Assessment: Document patient assessments, including normal findings, abnormalities, and reassessments.
  • Cardiac Arrest: Record cardiac arrest information, CPR, AED usage, patient rhythms, and return of spontaneous circulation (ROSC).
  • Stroke: Document stroke-related patient information.
  • Injury: Record injury-related information, including automatic crash notification (ACN) data when applicable.

Each section contains fields that help capture information relevant to the patient's condition and the incident.

Required Permissions

Users must have appropriate access to Incident Documentation and the EMS/ePCR functionality to create or edit patient care reports.

The specific First Due permission names and access levels should be verified against the agency's configured roles and permissions before publishing this article.

If a user cannot access or edit an EMS incident report, contact an agency administrator to review their assigned permissions.

Video

 

Step-by-Step Guide


Step 1: Access the EMS Incident Report

  1. Navigate to the Module Stack in First Due.
  2. Select Incident Documentation.
  3. Choose one of the following options:
    • EMS Homepage

    • EMS Incident List

  4. To create a new incident from the EMS Homepage, select Add New Incident.

  5. Alternatively, open an existing EMS incident report that is already in progress.

  6. On the left side of the incident report, select Assessments.

  7. The Assessments section displays the following tabs:
    • Situation
    • Impressions
    • Assessment
    • Cardiac Arrest
    • Stroke
    • Injury

 

Step 2: Navigate Between Assessment Sections

  1. Within the Assessments section, select the tab corresponding to the information you want to document.
  2. Selecting a tab automatically moves the report to that section.
  3. Navigate between sections as needed while completing the patient care report.
  4. Watch for red dots next to fields or sections. These indicate required information that must be completed before the report can be closed.

Step 3: Understand the Different Field Types

The Assessments section includes several field types and selection tools.

Not Applicable / Not Recorded

  1. Locate the icon displaying a line inside a circle.
  2. Select the icon to access the Not Applicable or Not Recorded options.
  3. Choose the appropriate response based on the information available.

Single-Selection Fields

  1. Locate the icon displaying three horizontal lines.
  2. Select the icon to open a list of available options on the right side of the screen.
  3. Use the search bar at the top to locate a specific option if necessary.
  4. Select the appropriate response.

Multi-Selection Fields

  1. Locate a button pack that displays square selection boxes.
  2. Select the applicable options.
  3. Multiple responses may be selected when supported by the field.

Date and Time Fields

  1. Locate the calendar or stopwatch icon associated with the field.
  2. Select the Calendar icon to manually enter or choose a date and time
  1. When available, select an existing incident time, including information previously imported from CAD.
  2. Select Apply to save the selected date and time.
  3. Alternatively, select the Stopwatch icon to record the current date and time.

Step 4: Complete the Situation Tab

  1. Select the Situation tab.
  2. Complete the applicable fields to document:
    • Whether an injury occurred
    • Whether the incident was work-related
    • Indications of alcohol use
    • Whether the incident involved a mass casualty event
    • Other events associated with the incident
  3. If applicable, document the patient's Triage Classification for transfer or transport.
  4. Review the section for required fields before continuing.

Step 5: Document Patient Complaints in the Impressions Tab

  1. Select the Impressions tab.
  2. Locate the Patient Complaints section.
  3. Select Add to create a new patient complaint.
  1. Choose the Chief Complaint, Secondary or Other.
  2. Enter the patient's complaint. For example, select Chest Pai

  3. Enter the duration of the complaint.

  4. Select the appropriate time measurement, such as minutes or hours.
  5. Select Save.

Adding a Secondary Complaint

  1. Select Add again within Patient Complaints.

  2. Choose Secondary as the complaint type.

  3. Select the applicable complaint, such as Weakness.
  4. Enter the duration and time measurement.
  5. Select Save.
  6. Review the primary and secondary complaints displayed in the report.
  7. If necessary, use the available Edit or Delete options to modify or remove a complaint.

Continue through the Impressions section to document applicable information, including:

  • Assessment date and time
  • Anatomic location
  • Organ systems
  • Associated symptoms

Step 6: Add a General Assessment

  1. Navigate to the Assessment tab.
  2. Locate the General Assessment section.

  3. Select Add

  4. A new assessment screen opens, displaying the available assessment categories.
  5. Select the applicable category to begin documenting findings.
  6. Record whether the findings are normal or represent the patient's normal baseline, as applicable.

Documenting No Abnormalities

  1. If the patient has no identified abnormalities, select the No Abnormalities option at the top of the assessment.
  2. This applies the corresponding normal findings across the available assessment categories.
  3. Review the populated findings to ensure they accurately represent the patient's condition.

Documenting an Abnormal Finding

  1. Select the assessment category requiring modification.
  2. Locate the appropriate anatomical area.
  3. Change the finding to reflect the patient's condition.

  4. For example, select Lower Extremities and document an abrasion on the patient's right toe.

  5. Select Save to retain the finding.
  6. Review the assessment to confirm the abnormality was recorded correctly.
  7. Select Save to save the completed general assessment.

Step 7: Add Additional Assessments and Time Stamps

  1. Within the General Assessment section, select Add to create another assessment.
  2. Select the Stopwatch icon to automatically record the current date and time.
  3. If the date or time needs to be corrected, select the existing date/time field.
  4. Update the information as needed.
  5. Confirm the change when prompted.
  6. Continue documenting the applicable assessment findings.
  7. Select Save when finished.

Using the Cardiac Arrest Assessment Shortcut

  1. When documenting a patient in cardiac arrest, select the Cardiac Arrest option at the top of the assessment screen.

  2. This automatically populates applicable assessment findings associated with cardiac arrest.
  3. Review the populated assessment categories.

  4. For example, open the Lungs category.

  5. Review the findings for the left and right lungs, which may be populated as absent breath sounds.
  6. Make any necessary changes to accurately reflect the patient's condition.
  7. Select Save.
  8. The additional assessment is displayed within the General Assessment section.

Step 8: Complete the Cardiac Arrest Tab

  1. Select the Cardiac Arrest tab.

  2. Indicate whether cardiac arrest occurred by selecting Yes or No.

  3. If applicable, complete the available cardiac arrest fields, including:
    • Date and time of cardiac arrest
    • Whether an AED was used
    • Who witnessed the arrest
    • Resuscitation attempts
    • Type of CPR provided
    • First recorded cardiac rhythm
    • Reason CPR was discontinued, if applicable
    • Return of spontaneous circulation (ROSC)
    • Time of sustained ROSC
    • End of cardiac arrest information
    • Type of bystander CPR provided
  4. For fields with selectable options, select the three horizontal lines to open the available choices.
  5. Select the appropriate responses based on the patient care provided.
  6. Review the completed fields for accuracy.

Step 9: Complete the Stroke Tab

  1. Select the Stroke tab.

  2. Review the available stroke-related fields.
  3. Document the applicable patient information, including whether stroke symptoms resolved.
  4. Complete any additional fields required by the report and relevant to the patient's condition.

Step 10: Complete the Injury Tab

  1. Select the Injury tab.
  2. Review and complete the applicable injury-related fields.

 

Step 11: Review the Assessments Section

  1. Navigate through each tab within Assessments.
  2. Review the information entered for accuracy and completeness.
  3. Check for any remaining red dots indicating required fields.
  4. Complete any outstanding required information.
  5. Verify that patient complaints, assessment findings, and relevant dates and times are accurate.
  6. Confirm that any applicable cardiac arrest, stroke, or injury information has been documented.
  7. Continue completing the remaining portions of the ePCR incident report as required by your agency.

Best Practices

  • Complete required fields: Review red-dot indicators to identify missing information before closing the report.
  • Document accurate time stamps: Use the stopwatch for events occurring at the current time and the calendar to enter or correct historical event times.
  • Review CAD-imported information: Confirm that any imported incident times accurately reflect the events being documented.
  • Use the correct complaint classification: Distinguish between primary and secondary patient complaints.
  • Document patient-specific abnormalities: When using the No Abnormalities option, verify that all populated findings accurately reflect the patient's assessment.
  • Review cardiac arrest shortcuts: Confirm that automatically populated findings match the actual patient condition.
  • Document reassessments: Add additional assessments when needed to reflect changes in patient condition over time.
  • Use Not Applicable and Not Recorded appropriately: Select these responses only when they accurately describe the information being documented.
  • Follow agency documentation protocols: Ensure that all assessment findings are consistent with patient care provided and applicable agency requirements.

Troubleshooting & FAQs

Why are red dots appearing in the Assessments section?

Red dots indicate required fields that have not been completed. Review the associated section and enter the necessary information before attempting to close the report.

How do I record the current time for an assessment?

Select the Stopwatch icon associated with the date/time field. This records the current date and time.

Can I change an assessment's date and time after it has been entered?

Yes. Select the existing date/time field and modify the information as needed. Confirm the change when prompted.

How do I document more than one patient complaint?

In the Impressions tab, select Add under Patient Complaints. Save the primary complaint, then select Add again to enter a secondary complaint.

Can I edit or delete a patient complaint after saving it?

Yes. Use the available Edit or Delete options associated with the saved complaint.

What is the difference between single-selection and multi-selection fields?

Single-selection fields allow users to choose one response from the available options. Multi-selection fields display square selection boxes and allow users to select multiple responses.

What happens when I select No Abnormalities in a general assessment?

The system populates the applicable assessment categories with normal findings. Users should review these findings and modify any category where an abnormality is present.

Can I document multiple general assessments in the same ePCR?

Yes. Select Add within the General Assessment section to create an additional assessment. Each assessment can have its own date, time, and findings.

What does the Cardiac Arrest shortcut do within a general assessment?

The Cardiac Arrest option automatically populates applicable assessment findings associated with cardiac arrest. Review and adjust the findings to ensure they accurately represent the patient's condition.

What does ROSC mean?

ROSC stands for Return of Spontaneous Circulation. The Cardiac Arrest tab includes fields for documenting ROSC and the time of sustained ROSC.

What is ACN data?

ACN stands for Automatic Crash Notification. When available, this information may be provided by a third-party service and can include vehicle-related details associated with a motor vehicle collision.

Why can't I access the Assessments section?

Verify that you have access to Incident Documentation and the appropriate EMS/ePCR functionality. If access is unavailable, contact your agency administrator to review your assigned permissions.