Purpose

1. To explain how to complete the Assessment section of an ePCR.
   
   

Related Articles

1. Completing an ePCR - 1. Response
2. Completing an ePCR - 2. Information
3. Completing an ePCR - 3. Assessment (This Article)
   
4. Completing an ePCR - General Assessment
5. Completing an ePCR - 4. Vital Signs
   
6. Completing an ePCR - 5. Treatments
   
7. Completing an ePCR - 6. Billing, Outcomes & External Reporting
   
8. Completing an ePCR - 7. Disposition & EMS Narrative
   
9. Completing an ePCR - 8. Signatures

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Background

The First Due ePCR workflow is designed to follow the following a typical EMS incident:

1. Response
   
2. Information
   
3. Assessment
   
4. Vital Signs
   
5. Treatments
   
6. Billing, Outcomes & External Reporting
   
7. Disposition & EMS Narrative
   

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Video

Directions

1. Once you have opened an incident, select the Assessment section from the menu of the left side of the ePCR.
   
   
   
   
   
   
   
   
   
   
   

   IMPORTANT: All NEMSIS required fields are notated with an asterisk (*). Depending on your state protocols, additional information could be required.
   
   
   
   
2. The Situation section of Assessment includes the following:
   
1. Possible Injury* - Indication whether or not there was an injury.
2. Work Related Illness/Injury - Indication of whether or not the illness or injury is work related.
3. Patient's Occupational Industry - The occupational industry of the patient's work.
4. Patient's Occupation - The occupation of the patient.
5. Alcohol Drugs use Indicators* - Indicators for the potential use of alcohol or drugs by the patient related to the patient's current illness or injury.
6. Patient Activity - The activity the patient was involved in at the time the patient experienced the onset of symptoms or experienced an injury.
7. Mass Casualty* - Indicator if this event would be considered a mass casualty incident (overwhelmed existing EMS resources).
   
   
   
   
   
   
3. The Impression section of Assessment includes Patient Complaints. To add a patient complaint, select the  button and input all available information and select .  The following are included in the Complaint section:
   
1. Complaint Type* - The type of patient healthcare complaint being documented.
2. Complaint - The statement of the problem by the patient or the history provider.
3. Symptom Onset Date & Time - The date and time the symptom began (or was discovered) as it relates to this EMS event. This is described or estimated by the patient, family, and/or healthcare professionals.
4. Duration - The duration of the complaint.
5. Time Units of Duration - The time units of the duration of the patient's complaint.
6. Chief Complaint Anatomic Location* - The primary anatomic location of the chief complaint as identified by EMS personnel.
7. Chief Complaint Organ System* - The primary organ system of the patient injured or medically affected.
   
   
   
   
   
   
   
4. Additionally, the Impressions section is composed of the following:
   
1. Last Known Well Date & Time - The estimated date and time the patient was last known to be well or in their usual state of health. This is described or estimated by the patient, family, and/or bystanders.
2. Last Oral Intake Date & Time - The date/time of last oral intake.
3. Primary Provider Impressions* - The EMS personnel's impression of the patient's primary problem or most significant condition which led to the management given to the patient (treatments, medications, or procedures).
4. Secondary Provider Impressions* - The EMS personnel's impression of the patient's secondary problem or most significant condition which led to the management given to the patient (treatments, medications, or procedures).
5. Initial Patient Acuity* - The acuity of the patient's condition upon EMS arrival at the scene.
6. Patient Registry - An indication if the patient may meet the entry criteria for an injury or illness specific registry.
7. Primary Symptom* - The primary sign and symptom present in the patient or observed by EMS personnel.
8. Other Associated Symptoms* - Other symptoms identified by the patient or observed by EMS personnel.
   
   
   
   
   
   
5. The Assessment section of Assessment allows the user to add a detailed General Assessment. To add an Assessment, select the  button.
   
1. For a detailed walkthrough of the General Assessment, check out the General Assessment Article.
   
   
   
   
   
6. Cardiac Arrest is the final section of Assessment. The Cardiac Arrest* drop down is required. If the incident did involve a cardiac arrest, the following will appear:
   
1. Arrest At Date & Time* - The date/time of the cardiac arrest (if not known, please estimate).
2. AED Prior to Arrival* - Documentation of AED use Prior to EMS arrival.
3. CPR PTA* - Documentation of the CPR provided prior to EMS arrival.
4. Witnessed By* - Indication of who the cardiac arrest was witnessed by.
5. Resuscitation Attempts* - Indication of an attempt to resuscitate the patient who is in cardiac arrest (attempted, not attempted due to DNR, etc.).
6. Type CPR Provided* - Documentation of the type/technique of CPR used by EMS.
7. Initial CPR At Date & Time - The initial date and time that CPR was started by anyone.
8. First Monitored Rhythm* - Documentation of what the first monitored arrest rhythm which was noted.
9. Rhythm at Destination* - The patient's cardiac rhythm upon delivery or transfer to the destination.
10. Resuscitation Discontinued at Date & Time - The date/time resuscitation was discontinued.
11. Reason for Discontinuation* - The reason that CPR or the resuscitation efforts were discontinued.
12. Is ROSC* - Indication whether or not there was any return of spontaneous circulation.
13. Arrest Etiology* - Indication of the etiology or cause of the cardiac arrest (classified as cardiac, non-cardiac, etc.).
14. End of Cardiac Arrest* - The patient's outcome at the end of the EMS event.