Purpose Statement

To explain how to complete the General Assessment section within the Assessment group of an ePCR (electronic Patient Care Record) in First Due. This section documents the patient's physical assessment findings across all body systems, capturing both positive findings and pertinent negatives required for comprehensive patient care documentation and NEMSIS compliance.

Background Information

The General Assessment section is a critical component of the ePCR Assessment group that allows EMS providers to systematically document their physical examination findings for each body system. This section supports clinical decision-making, ensures continuity of care, and meets regulatory requirements for patient assessment documentation. The assessment can be customized based on patient acuity levels and specific conditions such as cardiac arrest, with options to streamline documentation for lower acuity patients through automated normal findings and copy functionality for serial assessments.

Note: Agencies have the flexibility to customize their ePCR section order and subsection arrangements based on their specific workflow preferences and operational needs. The Assessment section and General Assessment subsection may appear in different positions within your agency's ePCR layout.

Required Permissions

• ePCR User permission to access and complete patient care records
• Field User access to incident-specific ePCR forms
• Write permissions for the assigned incident or assessment entries

Video

Step-by-Step Guide

1. Access the Assessment Group

Navigate to the Assessment group within your ePCR form. Locate the General Assessment section within your agency's configured layout.

2. Add a New Assessment Entry

Under the "Assessment" group, click on Add to create a new assessment entry for documentation.

3. Document Assessment Date and Time

Record the Assessment Date & Time using one of the following methods:

• Manual entry of the specific date and time
• Click on the clock icon to automatically document the current time

4. Select Body System for Assessment

Click on the appropriate body system to begin documenting assessment findings specific to that system. Available body systems typically include:

• Neurological
• Cardiovascular
• Respiratory
• Gastrointestinal
• Musculoskeletal
• Integumentary
• And other relevant systems

5. Document Assessment Findings

For each selected body system, document:

• Present signs & symptoms: Record all positive findings observed during examination
• Applicable pertinent negatives: Document relevant normal findings that rule out specific conditions or concerns

6. Save Assessment Findings

Click on Save to preserve your documented assessment findings for the selected body system.

7. Manage Assessment Entries

Use the trash can icon to delete body system assessment findings if corrections or removals are necessary.

8. Use "No Abnormalities" Toggle for Lower Acuity Patients

For patients with lower acuity presentations:

1. Activate the "No Abnormalities" toggle
2. This will automatically document "normal" findings across all body systems
3. Click on Save to preserve these default normal findings

9. Utilize Cardiac Arrest Assessment Toggle

For cardiac arrest patients:

1. Toggle on the Cardiac Arrest assessment
2. This will populate default assessment findings appropriate for cardiac arrest scenarios
3. Modify any findings as clinically indicated
4. Click on Save

10. Copy Previous Assessment Findings

To maintain consistency across serial assessments:

1. Click on Copy to duplicate all findings from the most recent assessment
2. Modify any changes or updates as clinically appropriate
3. Save the updated assessment

Best Practices

Assessment Documentation Standards:

• Document assessments in chronological order to show patient progression
• Include both positive findings and relevant pertinent negatives
• Use consistent medical terminology throughout all body system assessments
• Ensure assessment times accurately reflect when examinations were performed

Efficiency Tips:

• Use the "No Abnormalities" toggle for stable, lower acuity patients to streamline documentation
• Utilize the Copy function for serial assessments, then modify only changed findings
• Apply the Cardiac Arrest toggle when appropriate to auto-populate relevant findings

Clinical Accuracy:

• Ensure assessment findings support your clinical impressions and treatment decisions
• Document objective findings rather than subjective interpretations
• Include pertinent negatives that support differential diagnosis considerations
• Update assessments when patient condition changes significantly

System Navigation:

• Familiarize yourself with your agency's specific body system organization
• Save frequently to prevent data loss during documentation
• Use the delete function carefully to avoid removing necessary clinical information

Troubleshooting & FAQs

Common Issues:

Q: Assessment findings are not saving properly A: Ensure you click "Save" after documenting findings for each body system. Check that all required fields are completed before attempting to save.

Q: The "No Abnormalities" toggle is not working A: Verify that you have completed the assessment date/time before using the toggle. Ensure you save after activating the toggle function.

Q: Cardiac Arrest assessment defaults don't match my patient's presentation A: The toggle provides standard defaults that should be modified based on your specific patient assessment. Edit individual findings as clinically appropriate.

Q: Copy function is duplicating outdated information A: The Copy function replicates the most recent assessment. Review and modify all findings to reflect current patient status before saving.

Q: Body systems are missing or in different order A: Body system organization may be customized by your agency. Contact your system administrator if essential body systems appear to be missing.

Q: Assessment times don't reflect actual examination time A: Use manual time entry rather than the clock icon if you need to document a specific assessment time that differs from the current time.

Related Articles

• Completing an ePCR - Assessment
• Completing an ePCR - Vital Signs
• Completing an ePCR - Treatments
• Starting a New ePCR