Completing an ePCR - Information

Completing an ePCR - Information

Purpose Statement

To explain how to complete the Information section of an ePCR, including patient demographics, medical history, insurance information, and utilizing advanced features like driver's license scanning and patient search functionality to streamline data entry and improve documentation accuracy.

Background Information

The Information section of an ePCR captures critical patient demographic data, medical history, and insurance information required for proper patient care documentation and billing compliance. This section includes several NEMSIS-required fields for standardized EMS reporting. The platform offers automation features like driver's license scanning and patient search to reduce manual data entry and improve accuracy while maintaining HIPAA compliance standards.

Required Permissions

  • EMS module access permissions
  • ePCR Creation and Editing permissions
  • Patient Information Access permissions
  • Camera/Device Integration permissions (for driver's license scanning)
  • Patient Search Database Access permissions
Contact your system administrator if you cannot access specific sections within Information.

Video


Step-by-Step Guide

1. Navigate to the Information section

Access the ePCR form and locate the Information section within your agency's configured ePCR layout. The position may vary based on your agency's customized section order.

Alert
IMPORTANT: All NEMSIS required fields are notated with an asterisk (*). Depending on your state or local agency requirements, additional fields can be required.



2. Patient Information

The Patient Information section captures all pertinent patient information during an incident.

  1. EMS Patient ID: A unique identifier automatically generated by the system for each patient encounter. This field helps track patient interactions across multiple ePCRs and maintains continuity of care documentation within your agency's database.
  2. First Name: The patient's legal first name as it appears on official identification. This field is used for patient identification and billing purposes. Enter the complete first name without abbreviations when possible.
  3. Middle Initial/Name: The patient's middle name or middle initial. This optional field helps distinguish between patients with similar names and provides additional identification verification for billing and medical record accuracy.
  4. Last Name: The patient's legal last name or surname as it appears on official identification. This required field is essential for patient identification, billing, and medical record continuity.
  5. Gender* (Required): The patient's gender identity as reported by the patient or observed by EMS personnel. This NEMSIS-required field supports inclusive documentation practices:
    1. Female: Patient identifies as female
    2. Male: Patient identifies as male
    3. Unknown (Unable to Determine): Gender cannot be determined due to patient condition or other circumstances
    4. Female-to-Male, Transgender Male: Patient was assigned female at birth but identifies as male
    5. Male-to-Female, Transgender Female: Patient was assigned male at birth but identifies as female
    6. Other, neither exclusively male or female: Patient identifies as non-binary, genderfluid, or other gender identity
  • Race* (Required): The patient's racial background as self-reported or observed. This NEMSIS-required field supports demographic reporting and helps identify healthcare disparities. Select all applicable categories based on patient self-identification or visual assessment when patient is unable to respond.
  • Birth Date: The patient's date of birth in MM/DD/YYYY format. This field is crucial for age verification, medication dosing calculations, and patient identification. Use the Scan Driver's License feature when available to ensure accuracy.
  • Age* (Required): The patient's current age calculated from birth date or estimated based on appearance. This NEMSIS-required field is automatically calculated when birth date is entered, or can be manually entered when birth date is unknown.
  • Age Unit* (Required): The unit of measurement for the patient's age. This NEMSIS-required field ensures accurate age documentation, particularly important for pediatric and neonatal patients:
    • Years: Standard age measurement for patients over 2 years
    • Months: Used for infants and toddlers under 2 years
    • Days: Used for newborns and very young infants
    • Hours: Used for newborns in first days of life
    • Minutes: Used for newborns in immediate post-birth period
  1. Social Security Number: The patient's nine-digit Social Security Number without dashes or spaces. This optional field assists with patient identification and billing verification. Handle this sensitive information according to HIPAA privacy requirements.
  2. Driver License Number: The patient's state-issued driver's license or identification card number. Use the Scan Driver's License feature to automatically populate this field and reduce data entry errors.
  3. State Issuing Driver License: The state that issued the patient's driver's license or identification card. This field automatically populates when using the Scan Driver's License feature.
  4. Patient Resides Service Area: Indicates whether the patient's home address falls within your EMS agency's primary service area:
    1. Resident With EMS Service Area: Patient lives within your agency's coverage zone
    2. Not a Resident Within EMS Service Area: Patient lives outside your agency's coverage zone
  5. Alternate Home Residence: Special housing circumstances that may affect patient care, billing, or follow-up services:
    1. Homeless: Patient has no fixed address or permanent residence
    2. Migrant Worker: Patient is a temporary worker with transient housing
    3. Foreign Visitor: Patient is visiting from another country
  6. Home Address: The patient's primary residential street address including house number and street name. This field is essential for billing, follow-up care coordination, and demographic reporting.
  7. Street Address 2: Additional address information such as building name, floor number, or other location descriptors that help identify the patient's specific residence within a larger complex.
  8. Apartment Number: The specific apartment, unit, or suite number within a multi-unit residential building. This field ensures accurate mail delivery and location identification for future calls.
  9. Home City: The city or municipality where the patient resides. This field supports demographic reporting and billing address verification.
  10. Home State* (Required): The state where the patient resides. This NEMSIS-required field is essential for proper billing, demographic reporting, and interstate data sharing requirements.
  11. Home County* (Required): The county where the patient resides. This NEMSIS-required field supports regional health reporting and resource allocation analysis.
  12. Home Zip* (Required): The patient's residential ZIP code. This NEMSIS-required field is crucial for billing accuracy, demographic analysis, and geographic health trend reporting.
  13. Home Country: The country where the patient resides, defaulting to United States. This field supports international patient documentation and billing requirements.
  14. Home Census Tract: The U.S. Census Bureau designated tract number for the patient's residence. This field supports demographic research and community health assessment initiatives.
  15. Primary Phone Numbers: The patient's primary contact telephone number(s) with type designation (mobile, home, work). Use the "Add Phone Number" function to include multiple contact numbers for comprehensive patient communication.
  16. Primary Emails: The patient's primary email address with type designation (personal, work). Use the "Add Email" function to include multiple email addresses for patient communication and follow-up care coordination.




3. Scan a Driver's License

On a mobile device with working camera functionality, utilize the "Scan DL" feature to scan the barcode of a patient's state issued identification. All information will then be imported directly into the ePCR Patient Information fields. Verify with the patient all of the information on their identification is accurate before using it in your report.



4. Search Patient Feature

The "Search Patient" button performs a complete search of your stored patient records for both partial and complete matches of relevant patient information. To complete a patient information query, providers must first enter the patient's first name, last name, gender, and date of birth in MM/DD/YYYY format. Selecting the "Search Patient" button will begin the records search and give provider's potential or exact matches to link into your report.


5. Setting a Patient's Home Address

When a patient's address matches the incident address, the "Set Address from Scene" button will populate all scene information into the patient address fields. This allows providers to accurately and quickly enter relevant information without having to re-type any address related data. If the patient's address is different from the incident location, simply fill in the appropriate fields or utilize the "Scan DL" button referenced in Step 3. 




6. EMS Information

Enter in all necessary medical history into the EMS information section. See steps 11-13 to learn how to complete the EMS section of the report.
  1. Phone/Pager - Patient's primary contact phone number or pager for follow-up communication or coordination of care.
  2. Emergency Information Form - Indicates whether the patient has a completed emergency information form on file with personal details, medical conditions, and emergency contacts.
  3. Advance Directives - Legal documents or verbal instructions specifying the patient's wishes regarding medical treatment if they become unable to communicate their preferences. Options include:
    1. Family/Guardian request DNR (but no documentation) - Family requests Do Not Resuscitate but no official paperwork is present
    2. Living Will - Written document outlining patient's end-of-life care preferences
    3. None - No advance directives in place
    4. Other - Alternative directive not listed in standard categories
    5. Other Healthcare Advanced Directive Form - Non-standard healthcare directive document
    6. State EMS DNR or Medical Order Form - Official state-recognized DNR or physician order
  4. Patient Barriers to Care - Physical, cognitive, language, or social factors that may impede the patient's ability to receive or understand medical care.
  5. Medical/Surgical History - Previous medical conditions, diagnoses, surgeries, or significant health events relevant to current treatment.
  6. Medication Allergies - Known adverse reactions to prescription drugs, over-the-counter medications, or therapeutic substances.
  7. Environmental/Food Allergies - Allergic reactions to environmental triggers (pollen, dust) or food substances that may affect treatment decisions.
  8. History Obtained From - Source of the patient's medical history information when the patient cannot provide it directly.
  9. Currently Pregnant - Patient's pregnancy status with gestational age specifications for appropriate care protocols and transport decisions.
  10. Estimated Date - Expected due date for pregnant patients to anticipate delivery complications.
  11. # of Previous Pregnancies - Total number of times the patient has been pregnant (gravida).
  12. # of Previous Births - Number of live births the patient has delivered (para).
  13. Weight in lbs / kgs - Patient's current body weight for medication dosing calculations and equipment selection.
  14. Colormetric Length - Pediatric measurement using color-coded tape systems (like Broselow tape) to estimate weight and determine appropriate medication doses and equipment sizes for children.




7. Documenting "Not Values"

To document Not Values such as "Not Applicable" or "Not Recorded," simply click on the circle with a minus sign in the center, located just right of the answer box. This will populate a dropdown menu to input your not values, if applicable. Values shown below may be different than what your agency has set.




8. Documenting Patient History

There are two ways to document patient history into the EMS section of your report. First, providers can click within the answer box itself to populate a dropdown menu of all available answers. Some fields are multi-select while some are single select. This can be seen in the graphic below.




The second way to document within the EMS history section is the select the ellipsis on the right hand side of each answer box. This will populate a separate menu that allows you to search for specific results. This can be seen in the graphic below.



9. Patient Medications

To add a medication, type any current patient medication into the search bar between the trash can and Add. This will populate a search of the database for all matching medication names. Once selected from the list, providers can edit that medication using the Pencil icon to input dose, unit, and route. Providers can input medications quickly in bulk and edit later on, depending on department policies and procedures.













The Add button in the right hand corner of the Medications block will bring up the medication window to perform the same search function. Type any current patient medications into the Name search bar, click to select, and input any other relevant data before clicking Save.








10. Immunization and Practitioner Information

To input a patient's Immunization information, select the Add button on the right side of the Immunization block. This will populate the Immunization information window for providers to input all patient immunizations.





To input a patient's Primary Care Provider information, select the Add button on the right side of the Practitioner block. This will populate the Practitioner information window for providers to input all relevant care providers. 






11. Insurance Information

Enter in all necessary patient Insurance information. Additionally, providers can use the camera icon to take and upload a photo of all relevant insurance and billing documents.

  1. Relationship to the Insured - The patient's relationship to the person who holds the insurance policy (self, spouse, child, parent, etc.).
  2. First Name of the Insured - Given name of the individual who holds the insurance policy.
  3. Middle Initial/Name of the Insured - Middle name or initial of the policyholder for complete identification.
  4. Last Name of the Insured - Family name/surname of the insurance policyholder.
  5. Company Name - Full name of the insurance provider or carrier responsible for coverage.
  6. Company ID - Unique identifier code assigned to the insurance company for billing and processing purposes.
  7. Billing Priority - Ranking order for multiple insurance plans (primary, secondary, tertiary) to determine which insurance should be billed first.
  8. Group Name - Name of the employer, organization, or group through which the insurance coverage is provided.
  9. Group ID - Identification number assigned to the specific group or employer plan.
  10. Policy Number ID - Unique policy identification number assigned to the individual or family coverage plan.
  11. Company Address - Primary street address of the insurance company's billing or claims processing office.
  12. Street Address 2 - Additional address information such as suite number, floor, or department for the insurance company.
  13. Company City - City where the insurance company's billing office is located.
  14. Company State - State or province of the insurance company's billing address.
  15. Company Zip - Postal code for the insurance company's billing address.






12. Emergency Contacts Information

Enter all relevant emergency contact information, separate of the Relative/Guardian section. When entering in the emergency contact address, a drop-down field will appear performing a Google search. Providers also have the ability to upload any relevant patient information documents or photos in this section of the report.






13. Guardian and Relative Information

Input all Parent/Guardian information or closet relative, if applicable. Providers have the option to select the "Same as Patient Address" button to match contact information from the patient record. 



14. Employer Information

Enter in any applicable patient employer information, if applicable.




Best Practices

  • Always use the Scan Driver's License feature when available to minimize data entry errors and improve efficiency
  • Utilize the Search Patient feature before creating new patient records to avoid duplicates and maintain continuity of care
  • Verify address information carefully when choosing whether patient address matches incident location
  • Complete all applicable NEMSIS-required fields to ensure compliance with state and federal reporting requirements
  • When documenting medications, use the search function to ensure proper spelling and standardized naming conventions
  • Take clear photos of insurance cards to facilitate billing and reduce claim rejections
  • Document "Not Values" appropriately rather than leaving fields blank to maintain data integrity

Troubleshooting & FAQs

Q: The Scan Driver's License feature isn't working on my device. A: Ensure camera permissions are enabled for the First Due app and your device camera is functioning properly. Contact IT support if issues persist.

Q: I can't find a patient in the Search Patient feature. A: Verify spelling of search terms and try alternative search criteria such as partial names or different date ranges. The patient may be documented under slightly different information.

Q: Should I always match the patient address to the incident address? A: Only select this option if the patient's actual home address is the same as the incident location. Use separate addresses when the patient lives elsewhere but was treated at the incident scene.

Q: What if a medication isn't found in the search database? A: Contact your system administrator to request addition of missing medications to the database, or document in the narrative section as a temporary measure.




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