The Assessment section of the Electronic Patient Care Report (ePCR) enables responders to comprehensively document patient condition, clinical findings, and situational factors across multiple specialized subsections. This structured approach ensures complete medical documentation, supports clinical decision-making, and meets regulatory reporting requirements for various emergency scenarios including medical calls, cardiac arrests, strokes, and traumatic injuries.
Background Information
The Assessment section is one of the most critical components of the ePCR, serving as the primary clinical documentation tool for patient encounters. This section adapts dynamically based on the type of call and patient presentation, ensuring responders capture all relevant information without navigating unnecessary fields.
Reason for Transfer/Transport: Select appropriate reason
Step 3: Document Impressions
Adding Chief Complaints:
Click Select Add button
Choose Complaint Type from dropdown
Enter Complaint description
Specify Duration of complaint
Select Time Units (minutes, hours, days, etc.)
Click Save
Managing Complaints:
1. Edit: Click on individual complaint entry to modify
2. Delete Single Entry: Click trash icon next to specific complaint
3. Select the header checkbox to select entries
4. Bulk Delete: Click trash can icon
Additional Impression Fields:
Symptoms: Document presenting symptoms using the selection tool
Provider Impressions: Enter clinical impressions/differential diagnoses
Patient Acuity: Select appropriate acuity level
Other Associated Symptoms: Use the selection manager to add/remove symptoms
Step 4: Complete General Assessment
The general physical assessment is documented in the Assessment subsection.
Note: Due to the extensive nature of this section, refer to the dedicated Knowledge Base article: Completing an EPCR - General Assessmentfor detailed step-by-step instructions.
Step 5: Document Cardiac Arrest Information (If Applicable)
Complete the following fields when cardiac arrest occurred:
Don't guess at times—use the benchmark selector or stopwatch for accuracy
Don't leave required fields blank—use "Not Recorded" if information is unavailable
Don't duplicate information—each subsection serves a specific purpose
Don't rush through cardiac arrest documentation—accuracy is critical for quality improvement and reporting
Don't forget to check for ACN data on motor vehicle collisions—this valuable information aids documentation
Don't use vague or unclear complaint descriptions—be specific and clinical.
Don't document assessments you didn't perform—accuracy is essential for legal and clinical purposes
Tips & Recommendations
Navigation Efficiency: Click directly on subsection headings to jump to specific areas rather than scrolling
Bulk Entry: When adding multiple similar complaints or symptoms, use the bulk management features
Search Shortcuts: In selection lists, type the first few letters to quickly filter options
Time Management: Complete time-critical sections (Cardiac Arrest, Stroke) immediately after patient contact
Clinical Accuracy: Coordinate with your partner to ensure assessment documentation matches physical findings
Quality Documentation: More detail is better—thorough documentation supports patient care continuity and legal protection
Device Optimization: Familiarize yourself with touch vs. mouse interactions based on your device type
Protocol Alignment: Ensure your documentation aligns with your agency's clinical protocols and guidelines
Troubleshooting & FAQs
Q: The red dot won't disappear even though I've filled out all visible fields. What's wrong?
A: Scroll through the entire subsection carefully—some required fields may be below the fold. Also check if conditional fields have appeared based on your previous selections (e.g., if you indicated cardiac arrest occurred, additional required fields populate).
Q: I can't find a specific complaint or symptom in the dropdown list. What should I do?
A: Use the search function within the selection list by typing key terms. If still not found, look for a more general category or contact your system administrator about adding custom options if your agency permits.
Q: Can I go back and edit the Assessment section after completing the EPCR?
A: Yes, as long as the EPCR hasn't been locked or finalized according to your agency's policies. However, some organizations restrict editing after a certain time period or submission. Check with your supervisor about your agency's amendment policies.
Q: The Injury section isn't appearing even though my patient has trauma. How do I access it?
A: The Injury subsection appears conditionally. Ensure you've indicated an injury in the Situation subsection or selected an injury-related complaint type in Impressions. The section should populate automatically based on these triggers.
Q: What's the difference between "Not Applicable" and "Not Recorded"?
A: Use "Not Applicable" when the field doesn't pertain to your specific patient situation (e.g., airbag deployment for a non-MVC patient). Use "Not Recorded" when the information is relevant but unavailable or wasn't assessed (e.g., unknown time of symptom onset).
Q: How do I delete all complaints at once instead of one at a time?
A: Click the checkbox in the header row to select all complaints, or individually check the boxes next to each complaint you want to remove. Then click the trash can icon to bulk delete.
Q: The time selector shows benchmark times I don't recognize. What are these?
A: Benchmark times are key incident timestamps (dispatch, en route, on scene, etc.) automatically pulled from your CAD or incident data. These help you accurately document assessment times relative to incident timeline without manual calculation.
Q: I accidentally marked a field as "Not Applicable" but need to enter data. How do I undo this?
A: Click the checkbox icon again to deselect the "Not Applicable" option. The field should return to its normal input state, allowing you to enter data.
Q: Do I need to complete every subsection for every patient?
A: Complete all subsections that are clinically relevant and any that show red dot indicators for required fields. Use "Not Applicable" appropriately for irrelevant sections rather than skipping them entirely.
Q: Can I copy assessment information from a previous EPCR?
A: This depends on your system configuration. Some agencies enable templates or previous report copying. Check your system's functionality or consult your training officer. However, always verify and update information for the current patient—never submit copied data without review.
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