Managing Patient Records

Managing Patient Records

Purpose Statement

  1. This article demonstrates the use of the Patient Record Management section, which allows authorized personnel to view, edit, and manage comprehensive patient information across all ePCR documentation within the system.

Background Information

  1. The Patient Record Management section provides a centralized location for managing all patient information that has been entered into ePCRs within First Due. This functionality allows authorized users to maintain accurate patient demographics, medical history, contact information, insurance details, and employer information across multiple incidents and encounters.
  2. Patient record management is essential for maintaining continuity of care information, updating patient demographics as they change over time, and ensuring accurate patient identification across multiple EMS encounters. The system links all incidents associated with a specific patient, providing a comprehensive view of their EMS interaction history while maintaining proper access controls through permission-based viewing.

Required Permissions

To complete this task, users need the following First Due permissions:
Manage Patient Information
  • Allow
My EMS Care Reports
  • Read
  • Update (for viewing associated ePCRs)
View Other's EMS Care Reports
  • Allow (for comprehensive patient record management)
The "Manage Patient Information" permission is specifically required within the ePCR bucket to access and modify patient records in the Patient Record Management section.

Video


Step-by-Step Guide

Step 1: Navigate to Patient Record Management
  1. Navigate to Incident Documentation and select Patient Record Management
  2. Patient Record Management displays all patients that have been entered into an ePCR on First Due
  3. The system shows captured information about each patient from all their ePCR encounters
  4. Access to viewing and managing patient records is permission-based and assigned through the "Manage Patient Information" permission


Navigate to Incident documentation and select on Patient Record Management.



Step 2: Search for Patient Records
  • Use the filter tools to search for existing patient records
  • Apply appropriate search criteria to locate specific patients


Search for Patient Records



Step 3: Edit Patient Records
  • Use the pencil icon to edit a selected patient record


Edit Patient Records



Step 4: Update Patient Demographics
  1. From the PATIENT section, update patient demographics as needed


From the Patient section



Step 5: Update Medical History
  1. From the EMS section, update medical history information


From the EMS section



Step 6: Update Employer Information
  1. From the EMPLOYER section, update any employer information


From the Employer



Step 7: Update Guardian Information
  1. From the CLOSEST RELATIVE GUARDIAN section, update guardian information


From the CLOSEST RELATIVE GUARDIAN



Step 8: Add or Update Insurance Information
  1. From the INSURANCE section, update existing insurance or add new insurance by selecting the Add Insurance button


From the Insurance section



Step 9: Complete Insurance Details
  1. When adding insurance, a create insurance modal will appear
  2. Fill in all applicable fields and select Save


When adding insurance a create insurance modal will appear.



Step 10: Review Patient Incident History
  1. Use the Incidents tab to view all incidents associated with the selected patient
  2. This provides a comprehensive history of EMS encounters for the patient
  3. Use the view icon to access the ePCR for any selected incident
  4. This allows review of specific encounter details and documentation


Review Patient Incident History



Step 11: Manage Active Record Status
  1. Use the Active Record toggle to control whether the selected patient appears in ePCR documentation when searching for patients
  2. Deactivating a record removes the patient from search results in future ePCR documentation


Use the Active Record toggle to have the selected patient no longer appear in ePCR documentation when searching for patients.



Step 12: Save Changes
  1. When completed with managing patient records, select Save to preserve all updates


When completed with managing patient records select Save.

Best Practices

  1. Regularly update patient information to maintain accuracy across all encounters
  2. Verify patient identity before making changes to avoid updating incorrect records
  3. Use consistent formatting for patient names and demographics to improve searchability
  4. Keep insurance information current to facilitate billing processes
  5. Update guardian information for pediatric or dependent patients as needed
  6. Review incident history before updating patient records to understand the full context
  7. Use the Active Record toggle judiciously to avoid inadvertently hiding legitimate patient records
  8. Coordinate with clinical staff when updating medical history information
  9. Maintain patient privacy and confidentiality when accessing records

Troubleshooting & FAQs

Why can't I access Patient Record Management?
  1. Ensure you have the "Manage Patient Information" permission enabled within the ePCR bucket. Contact your administrator if this permission is missing.
What does deactivating an Active Record do?
  1. Deactivating removes the patient from search results when creating new ePCR documentation, but preserves all historical data and records.
Can I add multiple insurance policies for one patient?
  1. Yes, use the Add Insurance button to add additional insurance policies as needed.
How do I update information if I'm unsure about accuracy?
  1. Review the patient's incident history and consult with clinical staff or the patient/family when possible to verify information accuracy.
What happens when I update patient information?
  1. Updates apply to the master patient record and will be reflected in all associated incidents and future encounters.
Can I see who made previous changes to patient records?
  1. The system maintains audit trails for patient record changes. Contact your administrator for specific change history information.
How do I handle outdated insurance information?
  1. Update existing insurance entries or add new policies as appropriate. Consider deactivating outdated policies if your system supports this functionality.

    • Related Articles

    • 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 ...

    • ePCR - Search Patient Feature

      Purpose Statement This feature allows field personnel to quickly search for and attach previous patient care records from past incidents within their department to current EMS reports. By linking historical patient data, crews can access critical ...

    • Completing a Fire Incident Report - Associated Records

      Purpose Statement The purpose of this article is to explain how to view, link, or unlink EMS records using the Associated Records section within a Fire Incident Report. This feature enables seamless integration between Fire and EMS documentation, ...

    • Managing Occupancy Status - Active / Inactive

      Purpose Statement This feature allows authorized users to change occupancy status between Active and Inactive within the Pre-Planning module. Active occupancies appear in standard searches and operations, while Inactive occupancies are preserved in ...

    • NERIS Documentation - Associated Records

      Purpose Statement The purpose of this article is to explain how to view, link, or unlink EMS records using the Associated Records section within a Fire Incident Report. This feature enables seamless integration between Fire and EMS documentation, ...