Purpose Statement

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.

Key Features:

• Modular Design: Six specialized subsections (Situation, Impressions, Assessment, Cardiac Arrest, Stroke, Injury)
• Visual Indicators: Red dot notifications for incomplete required fields
• Flexible Data Entry: Multiple input methods including dropdowns, search functions, and quick-select options
• Time Stamping: Built-in benchmark times and current time population for accurate chronological documentation

Common Use Cases:

• Medical emergency documentation
• Cardiac arrest management and reporting
• Stroke assessment and time-critical documentation
• Trauma and injury reporting
• Multi-casualty incident documentation

Prerequisites:

• Active patient record/EPCR in progress
• Basic familiarity with EPCR navigation
• Understanding of clinical terminology and assessment protocols

Required Permissions

To complete the Assessment section of an EPCR, users need:

• EPCR Creation/Edit Permission - Ability to create and modify patient care reports
• Field-level permissions may vary based on your organization's configuration

Note: Contact your system administrator if you cannot access or edit Assessment fields.

Video

Step-by-Step Guide

Step 1: Navigate to the Assessment Section

1. Open the active ePCR for your patient
2. Locate and click on the Assessment section in the main ePCR navigation
   
   
   
   
3. Observe the subsection headings displayed at the top of the section.
   
   
   
   
   

Understanding Visual Indicators

Red Dot Notifications:

• A red dot next to any subsection heading indicates incomplete required fields
• Click the subsection heading to navigate directly to that area
• Complete all required fields to clear the notification

Field Input Indicators:

• Circle/Line icon   : Click to mark field as "Not Applicable" or "Not Recorded"
  
  
• List icon  : Opens a selection list on the right side of the screen with search functionality
  
  
• Calendar/Clock icon  : Opens date and time selector along with with incident benchmark times
  
  
• Stopwatch icon  : Automatically populates current date and time into the field
  
  
  

Step 2: Complete the Situation Subsection

Document the following fields as applicable:

1. Injury Occurred: Yes/No indicator
2. Work-Related Issue: Document if incident is occupational
3. Alcohol or Drug Use Indicators: Any signs of alcohol involvement
4. Mass Casualty Incident: Indicate if MCI protocols apply
5. Event Type: Select associated event classification
6. Triage Classification: Document triage category (if applicable)
7. Reason for Transfer/Transport: Select appropriate reason
   

Step 3: Document Impressions

Adding Chief Complaints:

1. Click Select Add button
   
   
   
   
2. Choose Complaint Type from dropdown
3. Enter Complaint description
4. Specify Duration of complaint
5. Select Time Units (minutes, hours, days, etc.)
6. 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:

1. Symptoms: Document presenting symptoms using the selection tool
2. Provider Impressions: Enter clinical impressions/differential diagnoses
3. Patient Acuity: Select appropriate acuity level
4. 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 Assessment for detailed step-by-step instructions.

Step 5: Document Cardiac Arrest Information (If Applicable)

Complete the following fields when cardiac arrest occurred:

Arrest Details:

1. Arrest Occurred: Yes/No
2. Date and Time of Arrest: Use time selector
3. AED Used Prior to EMS Arrival: Yes/No/Unknown
4. Arrest Witnessed By: Select witness type
5. Resuscitation Initiated Prior to EMS: Yes/No
   
   
   
   

6. Type of CPR Provided: Select method

7. CPR Initiated: Document start time

8. Initial Cardiac Rhythm: Document presenting rhythm

9. Cardiac Rhythm at Transfer: Document final rhythm

10. When Resuscitation was Discontinued: Document time if applicable

11. Reason Resuscitation was Discontinued: Select appropriate reason

12. Return of Spontaneous Circulation (ROSC): Yes/No

13. Etiology of Arrest: Document suspected cause

14. Outcome Upon Transfer of Care: Select disposition

15. Who First Started CPR: Record provider/bystander

16. Who First Applied AED: Document first responder

17. Who First Defibrillated: Record defibrillation provider

18. Therapeutic Hypothermia Used by EMS: Yes/No

Step 6: Complete Stroke Assessment (If Applicable)

Document stroke-specific information:

1. Stroke Symptoms Resolved: Yes/No indicator
2. Patient's Gait/Mobility: Document mobility status and limitations
   

Step 7: Document Injury Information (If Applicable)

The Injury subsection appears when trauma is indicated:

Basic Injury Documentation:

1. Cause of Injury: Select primary cause
2. Mechanism of Injury: Document specific mechanism
3. Trauma Triage Criteria: Indicate any met criteria
4. Vehicle Impact Area: For motor vehicle collisions
   

5. Patient Location: Document where patient was found

6. Safety Equipment Used: Seatbelt, helmet, protective gear, etc.

7. Airbag Deployment: Document deployment status

8. Height of Fall: Enter measurement if fall-related

1. Toggle ACN Information to ON if ACN data is available
1. Additional fields will populate automatically
   
2. Document information for each vehicle occupant as needed
   

Step 8: Review and Verify Completion

1. Check for any remaining red dot indicators
2. Review all subsections for accuracy and completeness
3. Use the "Not Applicable" or "Not Recorded" options appropriately for non-relevant fields
4. Verify all time-sensitive documentation (cardiac arrest, stroke) is accurate
   
   
   

Best Practices

Do's

1. Complete fields in real-time during patient contact when possible to ensure accuracy
2. Use the search function in dropdown menus to quickly locate specific selections
3. Document all applicable subsections even if only partially relevant to maintain comprehensive records
4. Utilize time stamps accurately, especially for time-critical conditions (cardiac arrest, stroke)
5. Mark fields as "Not Applicable" when they don't pertain to your patient rather than leaving them blank
6. Use the stopwatch feature for real-time documentation to ensure accuracy
7. Review red dot indicators before completing the EPCR to ensure all required fields are documented
8. Reference incident benchmark times when documenting chronological events
9. Document negative findings (symptoms not present) when clinically relevant
10. Save frequently if your system doesn't auto-save to prevent data loss

Don'ts

1. Don't skip subsections thinking they're optional—red dots indicate required documentation
2. Don't guess at times—use the benchmark selector or stopwatch for accuracy
3. Don't leave required fields blank—use "Not Recorded" if information is unavailable
4. Don't duplicate information—each subsection serves a specific purpose
5. Don't rush through cardiac arrest documentation—accuracy is critical for quality improvement and reporting
6. Don't forget to check for ACN data on motor vehicle collisions—this valuable information aids documentation
7. Don't use vague or unclear complaint descriptions—be specific and clinical.
   
8. Don't document assessments you didn't perform—accuracy is essential for legal and clinical purposes
   

Tips & Recommendations

1. ​Navigation Efficiency: Click directly on subsection headings to jump to specific areas rather than scrolling
   
2. Bulk Entry: When adding multiple similar complaints or symptoms, use the bulk management features
3. Search Shortcuts: In selection lists, type the first few letters to quickly filter options
   
4. Time Management: Complete time-critical sections (Cardiac Arrest, Stroke) immediately after patient contact
   
5. Clinical Accuracy: Coordinate with your partner to ensure assessment documentation matches physical findings
6. Quality Documentation: More detail is better—thorough documentation supports patient care continuity and legal protection
7. Device Optimization: Familiarize yourself with touch vs. mouse interactions based on your device type
8. Protocol Alignment: Ensure your documentation aligns with your agency's clinical protocols and guidelines
   

Troubleshooting & FAQs

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.