Leaving a PCR
As we all know the PCR is an important medical/ legal document that becomes a part of the Patient’s Medical Record. In an attempt to usher in the era of electronic charting the Midstate REMAC had allowed up to a two hour window to get your electronic chart completed and faxed to the ED. As a result of this two hour window for electronic charts we have experienced an unacceptable number of all types of PCRs arriving to the EDs several hours and sometimes days later. This created several problems and complaints were coming, not only from EDs but other hospital departments who needed the PCR to continue care. Also we now find ourselves non compliant with DOH Policy 02-05 which requires a PCR be left before leaving the hospital. On Aug 24ththe Midstate REMAC rescinded the two hour window. Effective immediately all Patient Care Reports must be completed and left before leaving the hospital. The REMAC did recognize there will be times when you are forced to clear the hospital for a call holding but these instances should be extremely rare. If you do need to clear, a detailed verbal report needs to be given and the PCR needs to be completed and returned to the ED ASAP. No controlled substances will be released from the St. Luke’s Pharmacy without the presentation of a completed copy of the PCR. If you have any questions feel free to contact the EMS Program Agency for assistance.