1 Alabama Office of Emergency Medical Services Patient Care

Alabama Office of Emergency Medical Services

Patient Care Reporting Guidelines

Updated January 12, 2024

OVERVIEW

Electronic Patient Care Reports serve as mandated, standardized and time‐validated permanent records

of the responses of EMS crews to the calls for help of ill and injured citizens and the disposition of those

cases. They serve many purposes including as sources of investigative and research data, sources of

case history for clinicians and insurance payers, and as documentation protective against litigation.

BACKGROUND

“NEMSIS” is an acronym for the National Emergency Medical Services Information System. Alabama has

participated in NEMSIS along with all other states and some territories since 2003. States and

participating territories are under agreement with the federal government under a memorandum of

understanding to require and collect electronic patient care reports and to subsequently transmit a

specified portion of each report to the NEMSIS records repository in Utah. Submitted data is used at the

federal, state, regional, local and service levels for research purposes.

RESPONSIBILITY

• Emergency Medical Services Personnel are responsible for the completion and submission of an

electronic Patient Care Report (e‐PCR) to the Emergency Medical Provider Service for who the

patient care was provided. (EMS Rules 2020: 420‐2‐1‐ .21 (1))

• Emergency Medical Provider Service operators are required to acquire and maintain access to

an electronic patient care reporting software (approved by the OEMS Director) to provide a

mechanism for their personnel to create and submit e‐PCRs. (EMS RULES 2020: 420‐2‐1‐ .11 (5)

6., 420‐2‐1‐ .21 (2))

TOPIC SECTIONS

• INTERPRETATION OF SITUATIONS REQUIRING e‐PCR DOCUMENTATION

1. In the operation of Emergency Medical Services, units are either dispatched to the location of a

call for help (passive detection) or while traveling, encounter a scene within which a call for help

exists (active detection). An EMS unit, in service and ready for call, has a duty to act if passively

or actively dispatched to a call for help within normal parameters of service.

2. Initiation of a patient care encounter begins with Incident Recognition and Access of the 9‐1‐1

System. Direct involvement of a provider begins with Access/Dispatch of that provider. At the

time of passive or active detection/dispatch, the Duty to Act of the provider is engaged to the

situation. Once the Duty to Act is engaged the case MUST be documented via e‐PCR.

3. Possible Dispositions Requiring Documentation – The dispositions listed were added to the

elements with initiation of Version 3.5. They are integrated to define the nature of the unit’s

actions and interactions more exactly. NOTE: An electronic patient care report (ePCR) is the

record of an EMS unit response and not just patient care. Every EMS unit responded to a scene

should complete an ePCR whether they participated in patient care or not.

eDisposition.27 (Unit Disposition)

• Patient Contact Made

• Cancelled on Scene

• Cancelled Prior to Arrival at Scene

• No Patient Contact

• No Patient Found

• Non-Patient Incident (Not Otherwise Listed)

eDisposition.28 (Patient Evaluation/Care)

• Patient Evaluated and Care Provided

• Patient Evaluated and Refused Care

• Patient Evaluated, No Care Required

• Patient Refused Evaluation/Care

• Patient Support Services Provided

eDisposition.29 (Crew Disposition)

• Initiated and Continued Primary Care

• Initiated Primary Care and Transferred to Another EMS Crew

• Provided Care Supporting Primary EMS Crew

• Assumed Primary Care from Another EMS Crew

• Incident Support Services Provided (Including Standby)

• Back in Service, No Care/Support Services Required

• Back in Service, Care/Support Services Refused

eDisposition.30 (Transport Disposition)

• Transport by This EMS Unit (This Crew Only)

• Transport by This EMS Unit, with a Member of Another Crew

• Transport by Another EMS Unit

• Transport by Another EMS Unit, with a Member of This Crew

• Patient Refused Transport

• Non-Patient Transport (Not Otherwise Listed)

• No Transport

eDisposition.31 (Reason for Refusal/Release)

• Against Medical Advice

• Patient/Guardian Indicates Ambulance Transport is Not Necessary

• Released Following Protocol Guidelines

• Released to Law Enforcement

• Patient/Guardian States Intent to Transport by Other Means

• DNR

• Medical/Physician Orders for Life Sustaining Treatment

• Other, Not Listed

eDisposition.32 (Level of Care Provided per Protocol)

• BLS – All Levels

• ALS – AEMT/Intermediate

• ALS – Paramedic

• EMS and Other Health Care

• Critical Care

• Integrated Health Care

• No Care Provided

4. Explanations/Examples of Dispositions Requiring Documentation

NOTE: All dispositions are valid for both emergency and non-emergency responses/situations.

Disposition/Item

Explanation/Example

eDisposition.27

UNIT DISPOSITION

Patient Contact Made

• Unit was dispatched to a scene where a patient was contacted.

• Unit was not dispatched but contacted a patient (“ran up” or “waved down” on a patient scene).

Cancelled on Scene

• Unit was dispatched, arrived on scene, and was cancelled (verbally or waved off) by someone with proper

authority to do so on scene.

• NOTE: Highly encouraged to document identity of who cancelled unit on scene.

Cancelled Prior to Arrival at

Scene.

• Responding unit is cancelled by entity with authority to do so.

• NOTE: Highly encouraged to document identity of who cancelled unit prior to arrival on scene.

No Patient Contact

• Responding unit arrives on scene to find patient (who exists) being transported by another EMS unit, POV

or law enforcement. No patient care relationship is established. NOTE: Highly encouraged to document

reason there was no contact.

No Patient Found

• Responding unit arrives on scene and does not find a patient at location of dispatch. NOTE: Highly

encouraged to document efforts to locate patient to establish due diligence.

Non-Patient Incident (Not

Otherwise Listed)

• Utilization of unit for non-patient related activity. Example: Body (decedent) transport. Fire standby

without patient interaction. Law Enforcement standby without patient interaction.

eDisposition.28

PATIENT EVALUATION/CARE

Patient Evaluated and Care

Provided

• At least primary assessment with provided care documented in other areas of report. NOTE: Highly

encouraged to take 2 or more sets of vital signs on every patient – in any situation.

Patient Evaluated and

Refused Care

• At least primary assessment. Refused any care. NOTE: Highly encouraged to extensively document efforts

to persuade patient to allow treatment. If patient will allow vitals to be taken, take 2 sets if possible.

Patient Evaluated, No Care

Required

• At least primary assessment. No obvious illness or injury. NOTE: Highly encouraged to extensively

document assessment, vitals, and pertinent negatives given situation. Example: Patient asked for unit

response to home only to request to have their vitals checked.

Patient Refused

Evaluation/Care

• Refusal for evaluation and care by a lucid patient legally able to make that decision. Chemical impairment

affects decision making. NOTE: Highly encouraged to document indicators of patient lucidity and efforts to

encourage patient care. HINT: If in doubt remember you can contact online medical control.

Patient Support Services

Provided

• No care necessary for a patient. Example: Lifted uninjured, otherwise normal patient from floor. NOTE:

Highly encouraged to document the reasons why illness or injury were not suspected. HINT: It is never a

bad idea to take a set of vitals on a patient lift assist even if they have no complaint.

eDisposition.29

CREW DISPOSITION

Initiated and Continued

Primary Care

Arrived on the scene first, and/or arrived on the scene as the highest level of provider on scene to assume

patient care responsibility. Continued care of patient throughout treatment and transport.

Initiated Primary Care and

Transferred to Another EMS

Crew

Arrived on the scene first, and/or arrived on the scene as the highest level of provider on scene to assume

patient care responsibility; transferred care responsibility to provider of equal or higher level on another EMS

crew, for purpose of transport, etc. NOTE: Highly encouraged to document name of service and provider

patient care was transferred to.

Provided Care Supporting

Primary EMS Crew

Arrived on scene and assisted primary crew in patient care. Worked cooperatively or under direction of

primary crew. NOTE: Highly encouraged to document functions provided and name of service and providers for

which care support was provided. Example: “Provided CPR and assisted with patient movement to unit.”

Assumed Primary Care from

Another EMS Crew

Arrived second on scene with transport responsibility, and/or as highest level of care provider, and received

patient care responsibility from initial crew. NOTE: Highly encouraged to document name of service and

provider from whom you assumed patient care responsibility.

Incident Support Services

Provided (Including Standby)

Dispatched/Scheduled for a support services situation. Includes standby status such as sporting events,

fireground standbys, law enforcement standby requests, delivery of equipment or supplies to a patient care

scene. NOTE: No patient care was provided by crew.

Back in Service, No

Care/Support Services

Required

Typically dispatched to scene for potential of supporting primary care providers and/or providing support

services and neither were needed or requested by care providers on scene. NOTE: Highly recommended to

document name of service and possibly providers on scene providing care.

Back in Service,

Care/Support Services

Refused

Typically dispatched to scene for potential of supporting primary care providers and/or providing support

services and upon offering assistance it was refused by care providers on scene. NOTE: Highly encouraged to

document name of service and provider declining offer of assistance.

eDisposition.30

TRANSPORT DISPOSITION

Transport by This EMS Unit

(This Crew Only)

The reporting unit crew transports patient to destination without a rider from another crew.

Transport by This EMS Unit,

with a Member of Another

Crew

The reporting unit transports patient to destination WITH a rider from another crew. NOTE: It does not matter

if the reporting unit crew or the rider has primary patient care responsibility.

Transport by Another EMS

Unit

The reporting unit has transferred care of the patient to the crew of the transporting unit.

Transport by Another EMS

Unit, with a Member of this

Unit.

The reporting unit has a crewmember that has remained with the patient while being transported by another

EMS unit. NOTE: It does not matter if the reporting unit crew or the rider has primary patient care

responsibility.

Patient Refused Transport

Patient was offered opportunity of transport to the destination (usually hospital) and refused the opportunity

of transport. NOTE: Highly recommend documentation of efforts to advise patient of any medical need to be

transported.

Non-Patient Transport (Not

Otherwise Listed)

Examples include transport of a decedent to the morgue or funeral home, transport of organs for

transplantation or medications needed by another unit or hospital. NOTE: Highly recommend documentation

of exact material transported and reason for transport by EMS unit.

No Transport

Unit arrived on scene with potential to transport and no transport occurred. Examples: Patient was found to

be deceased and no transport by this EMS unit was necessary. Patient was transported by law enforcement.

eDisposition.31

REASON FOR REFUSAL/RELEASE

Against Medical Advice

A lucid patient, under informed consent, refuses to be transported by your unit despite being warned

regarding the medical conditions necessitating transport and the possible consequences of refusing transport

and/or seeking medical care at the physician level. NOTE: Highly recommend extensive documentation of

assessment findings and efforts to inform patient and convince them to be transported.

Patient/Guardian Indicates

Ambulance Transport is Not

Necessary

A patient who is competent to make an informed medical decision in a situation where diligent assessment

yields no obvious indications of illness or injury, or a legally recognized guardian who is competent to make an

informed medical decision for an incompetent/underaged patient where diligent assessment yields no obvious

indications of illness or injury, declines transport. NOTE: Highly recommend extensive documentation of

situation parameters.

Released Following Protocol

Guidelines

See Alabama EMS Operational Guidelines, Section 18.07 Patient Rights and Refusal of Care. NOTE: Situation

does not qualify for “Against Medical Advice” category. Highly recommend extensive documentation of

situational parameters.

Released to Law

Enforcement

In lieu of EMS transport by this unit, patient is taken into custody by law enforcement.

Patient/Guardian States

Intent to Transport by Other

Means

In lieu of EMS transport by this unit, the patient, or their legally recognized guardian (for underage or

incompetent patient) declares their intent to transport to the destination facility via other means (privately

owned vehicle, etc.).

DNR

Patient has a Portable Do Not Resuscitate (DNR) or Pediatric Palliative or End of Life (PPEL) order and meets

standards outlined in EMS Rule 420-2-1-.04 and is not transported. NOTE: Unless a “DNAR”

or “PPEL” order is issued, any patient who sustains a cardiopulmonary arrest will receive full

cardiopulmonary resuscitation with the objective of restoring life. If a DNAR order has been

issued, the family may countermand that order and request that resuscitation be attempted. HINT: When in

doubt contact online medical control physician.

Medical/Physician Orders

for Life Sustaining Treatment

The patient is not transported and is released subsequent to physician direction. Typically, the patient is

judged by online medical control or physician in legal control of scene to have medical condition/injury that is

incompatible with life. Physician direction results in either the termination of prehospital intervention

(cessation of a code after 20 minutes without response) or withholding of resuscitative efforts due to

assessment findings or mechanism. NOTE: Name, location, MDPID (Medical Direction Physician Identification

Number) and communication with physician should be fully documented.

Other, Not Listed

Reason for Refusal/Release not otherwise categorized on this list. NOTE: The reason for Refusal/Release

indicated by this selection should be fully documented.

eDisposition.32

LEVEL OF CARE PROVIDED PER PROTOCOL

The level of care should be defined by the situation, medications, and procedures provided to the patient

based on what is allowed in the Alabama EMS protocols. This is not a reflection of the provider levels

providing care, but the actual care given-for example, BLS care provided by a paramedic would be entered as

"BLS". NEMSIS states that this element benefits reviews of performance, resource demand and utilization,

and reimbursement coding.

BLS – All Levels

Intervention provided was equivalent to the maximum available within the scope of practice of the Alabama

EMT

ALS – AEMT/Intermediate

Intervention provided was equivalent to the maximum available within the scope of practice of the Alabama

AEMT or the Alabama Intermediate.

ALS – Paramedic

Intervention provided was equivalent to the maximum available within the scope of practice of the Alabama

Paramedic.

EMS and Other Health Care

Intervention provided (typically during transport) was comprised of that provided by the unit EMS crew and

that of other health care providers not belonging to the crew. NOTE: Examples include EMS unit and crew

transporting a patient with a flight crew to or from a landing site or zone and EMS ground unit transporting a

hospital’s neonatal transport team

Critical Care

Intervention provided was equivalent to the maximum available within the scope of practice of the Alabama

Paramedic with Critical Care Endorsement.

Integrated Health Care

Intervention provided (typically during transport) was comprised of that provided by the unit EMS crew that

includes other health care providers (physician, R.N., etc.). NOTE: Example is EMS unit and crew composed of a

Paramedic and R.N. team.

No Care Provided

Intervention (by this unit) was unnecessary. NOTE: Examples include arriving second on scene and assisting a

care-providing-unit (while not personally providing patient care), transportation of a decedent (body),

medications, or equipment.

NOTES ON ELEMENTS VERSUS NARRATIVE

Elements are utilized on electronic formats for the purpose of categorization. Just because an element (or “click box”) exists

does not mean that further narrative documentation is unnecessary. For example, a procedure box can be used to document

the date and time of the procedure (endotracheal intubation, intravenous access, etc.) but it cannot document your reason for

performing the procedure. Rationale for procedures, medications, etc., are often reviewed in litigation and insurance

evaluations. Procedures and medications require INDICATIONS for application/administration. Due diligence in documentation

requires straightforward recording of the reasons why non-routine procedures (such as IV, ETT, defibrillation, etc.) are

performed. Further, often during litigation the case is tried years after the event took place. Straightforward narrative may be

the only method of recalling not “what you did” but “why you did it.”

5. Documentation of Refusals, Etc.

a. Documentation cannot be overemphasized in cases where patient care is applied and/or

suspended by patient request.

b. Refusals and suspensions by request absolutely require the patient to sign a waiver of

liability, or for a witness to sign witnessing the patient’s signature and/or decision to

refuse or suspend.

c. Witnesses to look for are family members, police officers, fire officials (not your

department) or unbiased bystanders.

d. An old rule of EMS is “If you didn’t write it down, you didn’t do it.” Meaning you cannot

prove in court that you did (or did not do) an action that was not documented.

• ALABAMA CUSTOM ELEMENTS

EMSA (Emergency Medical Stroke Assessment) Elements

The EMSA (Emergency Medical Stroke Assessment) Elements are custom elements unique to

Alabama. The purpose of EMSA is to assign a score to an acute stroke patient that reflects the

likelihood of the necessity of surgical intervention for an acute thrombo-occlusive stroke (surgical

thrombectomy). They reflect the assessment tool used in the stroke hospitals of the Alabama

Stroke System. The assessment tool was developed by Toby Gropin, MD, FAHA and others involved

in stroke management and associated with Alabama’s Acute Health System. Dr. Gropin is the

Director of the Comprehensive Neurovascular and Stroke Center at UAB.

Preliminary education for use of the EMSA tool was conducted among Alabama Emergency Medical

Provider Services (EMS Services and Departments) for approximately two years prior to the

introduction of the EMSA elements within Alabama’s NEMSIS reporting system on March 1,

2022. The e‐ PCR software vendors performing sales and service to our state’s Emergency Medical

Provider Services (EMPS) were made aware on 11/8/2021 of the addition of these custom elements

through the NEMSIS website. It is their responsibility to their clients to implement the EMSA

elements. As described in the preliminary training, it is the responsibility of each EMPS to assure

that the elements are set up in their vendor’s system utilized by them.

It is the responsibility of each individual licensee as the reporter of their e-PCR’s to both correctly

record data within the EMSA elements and to appropriately contact the state’s Trauma Call Center

(TCC) to enter an applicable patient into the Alabama Stroke System in the prehospital phase of

care. The Stroke System ID Number supplied by TCC operator is then to be entered into the e-PCR in

the appropriate place (eOutcome.04 – External Report ID/Number) and the system type element

(eOutcome.03 – External Report ID/Number Type) shall be selected as “Stroke Registry.”

EMSA is required to be utilized on every patient care report upon which patient assessment was

recorded and is recorded only once (not serially) during the patient care process. EMSA evaluation

should be used in conjunction with, and not as a replacement of, other stroke scales, such as the

Cincinnati Stroke Scale or FAST Stroke Scale. All NEMSIS software platforms used in Alabama should

include the EMSA elements. It is the recommendation of the Alabama OEMS that the first EMSA

element (emsa.SuspectedOccurrence‐EMSA‐Suspected Acute (New Onset) Stroke/CVA Occurrence)

be set by default to “No” or less preferably “Unknown.” It then can be selected as “Yes” if the

reporter suspects a new onset acute stroke has occurred.

OVERVIEW OF ELEMENTS AND THEIR USE

• emsa.SuspectedOccurrence‐EMSA‐Suspected Acute (New Onset) Stroke/CVA Occurrence “Do you

suspect an acute (new onset) stroke/cva occurred? CHOICES: Yes, No, Unknown

IF ABOVE ELEMENT IS ANSWERED “YES”

• emsa.TimeFactor‐EMSA‐Time Factor Date/Time “The approximate date/time that the complaint

was noticed.” 10 ANS: Date/Time

• emsa.Onset‐EMSA‐Onset “Was the onset of this complaint acute/rapid or gradual/slow?”

CHOICES: Acute/rapid, Gradual/slow

• emsa.Pain‐EMSA‐Pain “Does the patient experience head pain with this complaint?”

CHOICES: Yes, No

• emsa.AlabamaStrokeSystemEntry‐EMSA‐Alabama Stroke System Entry “Did you enter this patient

into the Alabama Stroke System?” CHOICES: Yes, No

• emsa.E1‐EMSA‐Horizontal Gaze “Patient Horizontal Gaze. Ask patient to keep their head still and

follow your finger left to right with their eyes.” CHOICES: Normal‐Equivalent Movement, Abnormal‐

Patient is unable to follow as well in one direction compared to the other.

• emsa.M2‐EMSA‐Facial Weakness “Facial Weakness. Ask patient to show their teeth or

smile.” CHOICES: Normal‐Bilaterally equivalent smile (both sides), Abnormal‐Unilateral facial droop

(one side does not move as well as the other).

• emsa.M3=EMSA‐Arm Weakness “Arm Weakness. Ask patient to hold out both arms, palms up, for

10 seconds with eyes closed.” CHOICES: Normal‐Both arms behave the same and do not drift away

or down from position start, Abnormal‐One arm does not move or drifts downward compared to

the other.

• emsa.M4‐EMSA‐Leg Weakness “Leg Weakness. Ask patient to lift up one leg and then the other,

hold 5 seconds each.” CHOICES: Normal‐Both legs behave the same and do not drift down during 5

second lift, Abnormal‐One leg does not move or drifts down compared to the other

• emsa.SA5‐EMSA‐Naming “Naming. Ask the patient to name your watch and pen (“What is the

name of this object?”)” CHOICES: Normal‐Patient clearly says “watch” or “pen” or gives brand name,

Abnormal‐Patient slurs words, says the wrong words (either one) or is unable to speak.

• emsa.SA6‐EMSA‐Repetition “Repetition. Ask the patient to repeat “They heard him speak on the

radio last night” after you.” CHOICES: Normal‐Patient remembers and clearly says the phrase when

requested, Abnormal‐ Patient slurs words, says the wrong words, or is unable to speak

NOTES:

**If you answer “YES” to the suspected occurrence question (Do you suspect a new onset

stroke/cva has occurred) then you will have to answer the other questions and the patient should be

put into the Alabama Stroke System.

**If you are on a call and are cancelled, or other situations where there IS NOT PATIENT CONTACT,

you should answer the suspected occurrence question (Do you suspect a new onset stroke/cva has

occurred) with either “NO” or “UNKNOWN”. YOU MUST ANSWER THIS QUESTION FOR THE e‐PCR to

pass validation.

The EMSA Score is a number between 0 and 6. For every question answered “abnormal” the patient

given 1 point. Completely normal is 0 points and any score greater than 4 is suspected of large

vessel occlusion (LVO) and may require thrombectomy. The scorable questions are contained in the

EMSA card included below. NOTE: Copies of this card are available on request from the Alabama

OEMS so it can be carried by individuals or placed on units for reference. The reporter is responsible

for including the EMSA score of an applicable patient into the body of the narrative. The TCC

operators began requesting the EMSA Score of a patient placed into the Statewide Stroke System on

April 29, 2022.

EMSA (Emergency Medical Stroke Assessment) was developed by the UAB Department of

Neurology. A video can be accessed in the following link: http://www.kaltura.com/tiny/xr3fh

• ACUTE HEALTH SYSTEMS DOCUMENTATION

1. Alabama Trauma and Health System (ATHS)

Alabama is the only state in the United States with the capability to constantly monitor the

status of every trauma hospital and route the trauma patient to the most appropriate hospital

every time. The system was developed to reduce the societal burden of trauma and to save

lives. The system itself collects data initiated by prehospital EMS and entered by participating

hospitals. Review of prehospital EMS data is often done to perform quality assurance and

quality improvement (QA/QI) for the Alabama Trauma System. Participating hospitals are

granted a designated as a Level 1, 2 or 3 Trauma Hospital based upon available physicians and

services. Level 1 Trauma Centers are the most capable to treat severe trauma.

The purpose of the ATHS is to maximize care for trauma patients with “The Golden Hour” of the

case. Patients who meet Alabama Trauma and Health System inclusion criteria should be “put

into the system” by the prehospital EMS team initiating care at the scene by calling the ATHS

Central Operator at 1‐800‐359‐0123. The operator will then advise the most appropriate

destination to treat the patient’s condition at the time of entry. Inclusion criteria and entry

instructions are listed in the Acute Health Systems/Trauma System protocol on pages 14‐16 of

the 10th Edition of the Alabama EMS Patient Care Protocols available online at the Alabama

OEMS website.

Documentation concerns for Trauma System entry are as follows:

The e‐PCR has two elements that should be filled when the TCC operator is called, and a trauma

number is given; eOutcome.03 (External Report ID/Number Type) should be selected as

“Trauma Registry” and eOutcome.04 (External Report ID/Number) should be the number given

by the ATCC operator (will be 6‐7 digits long). The e‐PCR also has element eInjury.03 which

should be a dropdown box with the criteria for transport to a trauma center. This field should

be populated with criteria requiring entry into the Trauma System.

2. Alabama Statewide Stroke System

The Alabama Statewide Stroke System was activated on October 30, 2017. The system works

similarly to the Trauma System, with the goal to be routing of the patient to the most

appropriate facility for the patient’s condition and early recognition of large vessel obstruction

which may require surgical intervention. Participating hospitals are designated as Level 1, 2, or

3 depending upon stroke treatment capabilities (physicians and services available).

The Emergency Medical Stroke Evaluation (EMSA) elements were integrated into the Alabama e‐

PCR as custom elements (as described above) to facilitate patient entry into the Stroke System.

If the first element, Suspected Occurrence of Acute Strove, is recorded as “yes” then the patient

care provider is expected to have called the Central Operator at 1‐800‐359‐0123 and entered

the patient into the Stroke System and to have received a number. The operator will route the

ambulance to the most appropriate destination hospital, call for helicopter EMS to transport if

necessary, and alert the destination hospital as done with severe trauma patients. Inclusion

criteria and entry instructions are listed in the Acute Health Systems/Stroke System protocol on

pages 17‐18 of the 10th Edition of the Alabama EMS Patient Care Protocols available online at

the Alabama OEMS website.

The e‐PCR has two elements that should be filled when the ATCC operator is called, and a stroke

number is given; eOutcome.03 (External Report ID/Number Type) should be selected as “Stroke

Registry” and eOutcome.04 (External Report ID/Number) should be the number given by the

ATCC operator (will be 6‐7 digits long). This is in addition to the completion of the EMSA

elements as described above. The EMSA score (0‐6) should be recorded within the narrative as

being the “EMSA Score = “if the patient is suspected of having an acute stroke.

3. The Alabama Statewide Cardiac/STEMI System

CARES

The Alabama Department of Public Health (ADPH) and the Office of Emergency Medical Services

(OEMS) have partnered with Cardiac Arrest Registry to Enhance Survival (CARES) to measure

and improve outcomes statewide from out of hospital cardiac arrest. Extra documentation is

not required for the CARES system to work.

STEMI System

A system like the Trauma and Stroke Systems is projected and under development to maximize

treatment of ST‐elevation myocardial infarction cases encountered in the prehospital

environment. Prehospital care providers would utilize 12‐lead electrocardiography and contact

the ATCC operator to be routed to the most appropriate facility to treat the patient’s condition.

The drop‐down box for eOutcome.03 (External Report ID/Number Type) can possibly contain a

14 choice “STEMI Registry” but it is not yet used statewide as the Statewide STEMI System is not

yet operational. The Birmingham Regional EMS System (BREMSS) currently has a region‐specific

STEMI system that may and should use those elements.

• BEST PRACTICES NARRATIVE DOCUMENTATION

Narrative documentation is neither straightforward or standardized in either EMS training or quality

assurance and improvement programs within most Alabama EMS services who submit e‐PCRs. The

following is an overview of functions that the narrative section of e‐PCR performs and various

preferred approaches to write narratives.

1. Function of the Narrative Section

Elements of an e‐PCR record and timestamp assessments, procedures, medication

administrations and record the response of the patient to each procedure and medication. Each

procedure and administration are recorded under its own unique identification number. The

elements are primarily used to count and categorize actions, for example, the number of

naloxone administrations in a period for a certain area. Compliance requires that all

assessments, procedures, and administrations be recorded in the appropriate elements.

The narrative section of an e‐PCR tells the complete story of a scene response and patient care

situation. It is likely the least understood part of the e‐PCR. The e‐PCR elements can tell a reader

what was done and when it was done, but they cannot convey “why” it was done. Any patient

care intervention must be done secondary to an “indication” (reason) for that intervention.

Every EMS Provider makes dozens of complex decisions on every call, based upon personal

scope of practice, training, and experience. Appropriate decisions are frequently made which

cannot be validated by information in a drop‐down menu. A wise EMS Provider gives rationale

for decisions made to enact treatment and transport of a patient. The best use of the narrative

is the following:

THIS IS WHAT I OBSERVED <‐> THIS IS WHAT I DID <‐> THIS IS WHY I DID IT

**OBJECTIVITY IS THE KEY TO GOOD DOCUMENTATION**

As the Patient Care Report serves as a prehospital medical record, treatment criteria must be

carefully documented to validate billing for services provided. Similarly Patient Care Reports

serve as a legal record for events that occurred on the call and may be used in legal processes to

validate the legality and necessity of actions of EMS providers on the scene. Least obviously,

Patient Care Reports are used in Quality Assurance and Quality Improvement processes at the

individual, service, city, county, region, state, and federal levels.

2. Approaches to Writing the Narrative

A professional narrative should be thorough. It should contain specific information pertaining to

the observation of situation, signs, symptoms, histories, and complaints; as well as any

precautions taken, and any interventions or treatments administered. Many e‐PCR platforms

will assist the reporter by placing data into the narrative. Many experienced reporters just use

an acronym to chart their own written thoughts in a concise flowing manner. Many use a

combination of the two methods cut save time while maximizing recorded information.

Whether or not an automated feature is utilized the narrative should be reviewed thoroughly

and edited to ensure that the 15 language is accurate, is readable and is EXACTLY what the

reporter wants on the report to provide facts that are accurate, defendable, and objective.

Always remember that your professional capacities and reputation are represented by what you

write and approve for submission.

1. Common Acronyms Used in Narratives

Generally, all aspects of a narrative should be accomplished in complete sentences with

appropriate punctuation. Remember, if you write like you are unprofessional you will look

unprofessional while you are defending your actions in court. Also, any narrative format

should start with the “who, what, where, when and why” of the dispatch process as well as

a description of what was found upon scene arrival, EVEN in cases of being cancelled on a

scene.

o S.O.A.P. NARRATIVE (Some variations exist.)

▪ Subjective – History of the incident. Why you were called. What you are told. How the

patient described their symptoms. Dispatch information and your perception of the scene.

▪ Objective – Comments are added in including your assessment findings, vehicle damage or

other observations, patient positioning, viral signs (at least, initial vital signs) EKG findings

and other non‐opinionated facts.

▪ Assessment – Your differential diagnosis (what you believe you are treating and what you

believe you are ruling out).

▪ Plan – What you did to treat your patient (interventions, IVs, medications) include what (if

any) was done prior to your arrival, what was done on scene and what was done in

transport.

o C.H.A.R.T. NARRATIVE (Some variations exist.)

▪ Complaint – Chief complaint (If patient’s own words, use “quote‐unquote” format – use

quotation marks).

▪ History – History of the present illness. Patient’s recent medical history. Patient’s chronic

medical history. Any pertinent history is outlined.

▪ Assessment ‐ Your differential diagnosis (what you believe you are treating and what you

believe you are ruling out).

▪ Rx – The patient’s prescriptions are listed.

▪ Treatment ‐ What you did to treat your patient (interventions, IVs, medications) include that

(if any) was done prior to your arrival, what was done on scene and what was done in

transport.

o D.R.A.A.T.T. NARRATIVE (method advocated by Page, Wolfberg and Wirth – National EMS Law

Firm and used herein with permission.)

▪ Dispatch – Dispatch information given. Your location when response began.

▪ Response – Mode of response. Notations of response process (obstructions, etc.).

▪ Arrival – Arrived on scene to find. Notations of arrival and observations.

▪ Assessment – Observations, differential diagnosis, etc.

▪ Treatment – What you did to treat your patient (interventions, IVs, medications) include

what (if any) was done prior to your arrival, what was done on scene.

▪ Transport – Documentation of aspects of transport to facility, including treatments,

observations, and issues.

o (Assessment Mnemonic) M.U.R.D.E.R.S.I.N.C. Systems Review Assessment

A review of each body system can be used under the “Assessment” of any mnemonic to indicate

either normal or abnormal findings for each body system. Normal findings can be listed as

“normal” or “unremarkable”. Use of this approach documents that each specific system was

considered in assessment.

▪ Muscular System –

▪ Urinary System –

▪ Reproductive System –

▪ Digestive System –

▪ Endocrine System –

▪ Respiratory System –

▪ Skeletal System –

▪ Integumentary System (skin) –

▪ Neurological System –

▪ Circulatory System –

The Systems Review Assessment is also useful for reminding the reporter to ask questions

regarding the system. For example, for Musculoskeletal System the assessor would note the

development of the muscles. Are they equivalent on either side or is there hypertrophy from

exercise or is there atrophy from lack or inability of use? Similarly, for the Urinary System

review, if the chief complaint is not urinary pain or other obvious issue, the examiner can ask

about changes in urine output including volume, color, smell, or discomfort during urination. A

review of the Reproductive System asks a male about any reproductive issues, such as erectile

dysfunction and whether any medication is used for that (very important if the patient is

experiencing chest pain or symptoms of M.I.). The same for a female asks about the possibility

of pregnancy, any history of pathology or surgeries, how many pregnancies have occurred, how

many miscarriages and how many live births have occurred

2. Common Problems with Narrative Documentation

o Narrative Conflicts with An Element

▪ Reporters sometime report something in the narrative that directly disputes the

indicated data of an element. For example, the elements that report the Glasgow Coma

Score (GCS) are eVitals.19 through eVitals23 are defaulted at “normal” and the reported

GCS = 15. The reporter describes the patient’s level of consciousness as “responsive to

pain”. The data conflicts.

▪ The result of conflicting data in a court will depend upon what the basis of the hearing

is. The presence of conflicting data is like the presence of conflicting statements given in

testimony in court. The conflicting information can bring the reliability, quality, and

judgement of the reporter into question. This inference can affect the case of the

litigating parties and may weaken the case of an EMS professional answering to defend

their own actions in the field.

▪ The e‐PCR reporter can avoid conflicting statements by carefully reviewing all elements

used and all verbiage in the narrative for correctness and appropriate content prior to

submitting the e‐PCR.

o The Automated Narrative Feature “Muddies” the Narrative

▪ Automated narrative devices used within e-PCR platforms are designed to place data

from e-PCR elements into the narrative to assist in writing the story of the patient care

process. Their use ranges from very helpful to detrimental to the narrative.

▪ Proper use of automated narrative features requires a careful review of the narrative

section of an e-PCR prior to submission into the EMS Data Repository. Any extraneous

text that may be generated into the narrative field should be edited out prior to

submission.

▪ EXAMPLE OF COMPLETE DATA AND RESULT:

• eVitals.19 (Glasgow Coma Score-Eye) = No Eye Movement = 1

• eVitals.20 (Glasgow Coma Score-Verbal) = No Response = 1

• eVitals.21 (Glasgow Coma Score-Motor) = No Response = 1

• eVitals.23 (Total Glasgow Coma Score) = 3

• Possible Narrative Generation: “The patient exhibited NO eye movement, NO

verbal response and NO motor response. Total Glasgow Coma Score = 3.”

▪ EXAMPLE OF INCOMPLETE DATA AND RESULT:

• eVitals.19 (Glasgow Coma Score-Eye) = (UNFILLED)

• eVitals.20 (Glasgow Coma Score-Verbal) = (UNFILLED)

• eVitals.21 (Glasgow Coma Score-Motor) = (UNFILLED)

• eVitals.23 (Total Glasgow Coma Score) = (UNFILLED)

• Possible Narrative Generation: “The patient exhibited Total Glasgow Coma

Score = .”

▪ Automated narrative inserts are specific for individual e-PCR platform software and are

often generated by selection of a “button” by the reporter. The actual range of inserted

content can usually be preprogrammed. If they are available to the reporter, and

especially if they are chosen to be used by the reporter, the text should be reviewed,

and any nonsensical text removed prior to “final saving” the report and submitting it to

the EMS Repository.

o Terse (short/too short) Narratives

▪ Narratives are meant to be descriptive, easily reviewable summaries of the unit’s

response, approach to and completion of patient care.

▪ Statements within narratives should describe the who, what, when, where, and why of

the EMS response. Statements that are too short are not beneficial for the crew

involved, for the clinicians or investigators reviewing the record, or the patient. The e-

PCR is the State’s legal record of the crew’s call to action, duty to act, and disposition of

the patient.

▪ Criteria describing the patient’s condition, assessment findings, observations,

treatments, and results should be indicated by the elements of the e-PCR and then

summarized within the narrative for quick evaluation by a reviewer of the record.

Reviewers may include clinicians, investigators, and attorneys.

▪ Description should be in complete sentences with appropriate grammar. Abbreviations

were previously accepted on hand-written narratives because of space constraints.

Electronic narratives typically do not have a maximum character count; thus,

abbreviations are neither necessary nor acceptable.

3. Overview of Uses for the Narrative

o Quick Reference for Clinicians

▪ Upon completion and submission of the e‐PCR the destination hospital has

access to the electronic record through the RESCUE EXCHANGE system (if the

appropriate facility ID code was included on the e‐PCR). The record then

becomes available for the physician team to review to determine what findings

and interventions occurred during the treatment and transport process.

▪ Physicians throughout the state have requested that some written form of

record be made available at the time of transfer of patient. Use of a written

note sheet is completely acceptable for this purpose and many ambulance

services already use such note sheets. The OEMS is in the process of developing

a note sheet for this purpose for distribution. ANY WRITTEN NOTE SHEET WILL

NOT REPLACE THE PROCEDURAL USE OF AN E‐PCR ON EVERY RESPONSE.

▪ The narrative provides a summarized statement of treatments performed and

observations made that many clinicians use to guide their in‐hospital treatments

of patients.

o Quick Reference for Insurance Payors

▪ The basis of successfully filing for insurance payment for EMS services is the

accurate reporting of indications, interventions, and responses on EMS

reporting documents.

▪ Mandatory refiling and review processes are often associated with insufficient

and vague charting of rationale and services provided to insurance clients.

Repetitive processes serve to slow down payment flow and to increase the costs

of filing with avoidable repetition.

▪ Insurance adjusters and investigators often center their documentation review

of patient care performed on the narrative section of the e‐PCR. The necessary

documentation may exist in the elements section of the report but may be

inadvertently missed by reviewers resulting in an extended or repeated review

process for the individual call.

o Quick Reference for Medico-Legal and Investigators

▪ In a legal review, if the reporter did not write an action down its completion will

remain in question. (“If you didn’t write it down you didn’t do it.”)

▪ Observations of EMS personnel are often important in determining safety of a

scene. Those observations should be recorded in situations where probable

crime investigations will occur. Such situations include, but are not limited to,

murders, suicides, assaults, accidents, etc.

▪ Any observation made that affects decisions, or may reasonably be questioned

later, should be recorded.

▪ Generally, it is preferable to have recorded an observation unnecessarily than to

have omitted an observation that should have been recorded.

 BEST PRACTICES FOR ELECTRONIC SUBMISSION

• Contracted e‐PCR platforms are responsible (per NEMSIS) for provision of a feature that

validates/indicates that a written e‐PCR will pass Alabama’s (or, nationwide, the state of

operation) Schematron. Technically an e‐PCR should not be allowed to submit unless it will pass

the state’s Schematron.

• Services have the option to set their submissions for either immediate submission by the

reporter or delayed submission pending supervisor review. No matter which method is used the

Emergency Medical Provider Service is responsible for assuring that an electronic patient care

report is submitted to the Alabama EMS Repository for any response their service performs, and

that the e-PCR is submitted within the required time period.

• Alabama OEMS provides several free platforms which can be used by Emergency Medical

Provider Service supervisory staff to monitor the e-PCR submission and to explore the dynamics

of the data recorded by their Service.

▪ Submission Summary Email

• May be requested by any Alabama licensed Emergency Medical Provider

Service.

• Received automated email on Monday mornings at 07:00 with number of

unique e-PCRs received in previous seven days (previous Monday at 00:00

to Sunday night at 23:59). Should be compared to run logs for same time

period.

• May designate two recipients per EMPS.

▪ Alabama NEMSIS V3 Submission Website

• May access and download State-form copies of e-PCRs.

• May lookup e-PCRs by Dispatch Notified Date, Incident Address, Incident #,

PCR #, or submission times.

• May search for e-PCRs by Crew Member ID (License Number), Recorded

Disposition, Incident Number, ATCC Number, Date of Incident (Range)

Incident Street Address, Incident City, Incident County, Patient Data (SSN.

Date of Birth, Age, First Name, Middle Name, Last Name, Destination Code

and Dispatch Complaint).

• May review submission groups (submitted e-PCRs by groups submitted).

• May review submission statistics (report counts, passes and fails).

▪ NEMSIS Data Portal (Dashboard)

• Has preset tools set up to review and cou8nt Incident Data, Medication

Data, Procedure Data and Report Submission Data.

• May download counts and statistics in EXCEL sheets.

• May download graphs in differing formats.

• Has presentation graphs that may be copied and pasted into performance

reports.

• IS DESIGNED TO AID IN WRITING REPORTS FOR REVIEWS, QA, QI, ETC.

 SUMMARY

1. The electronic patient care report (e-PCR) is the legally required record of a unit’s response to a

call for help. Each e-PCR records the disposition of the service and individual-level duty to act

and the patient/patients involved.

2. An e-PCR must be written and submitted for all EMS responses.

3. It is the legal responsibility of the unit’s crew to complete an appropriate e-PCR for any response

upon which they are dispatched or answer.

4. It is the legal responsibility of the Emergency Medical Provider Service (EMPS) to provide a

platform for the purpose of e-PCR completion and submission for their member’s employment-

related and assigned responses. It is further the responsibility of the EMPS to assure that all

employment-related e-PCRs are completed and submitted within the time limits of the EMS

rules.

5. The elements of the e-PCRs are designed to quickly record data that are descriptive of the

parameters of the response, which can be used to categorize findings and create an individual

record for a procedure/medication administration, and which do not require verbiage to

explain.

6. The narrative of the e-PCR is designed to “tell the story” of the response and disposition of the

response and describe the responder’s rationale for decisions made and actions taken. It

summarizes the call in a way that can be reviewed by clinicians, insurance personnel, law

enforcement personnel or attorneys to explain the steps taken by responders to best care for a

patient’s interests and to meet the requirements of the standard of care for the situation. The

narrative is considered the most important aspect of the e-PCR. It is a text box and can contain

a virtually unlimited amount of text, making it for superior to previous hand-written reports.

The quality of the narrative is often used to judge the competence and ability of the crew.

7. Several free-access electronic tools are made available to Alabama-licensed Emergency Medical

Provider Services upon request to enhance EMPS surveillance of its electronic reporting and to

aid with quantification of data for the purpose of QA, QI and response reporting.