An ePCR (Chart) shall be completed for each leg of a transport.

ePCRs are to be completed within one hour after a call. If extenuating circumstances (e.g., consecutive calls) delay documentation, the ePCR shall be completed at the earliest possible opportunity.

The type of chart depends on the transport type. We utilize three different chart types:

• Half Chart: Used when the flight program pays for the transport. Only basic patient information is documented.

• Full Chart: Used when the patient/insurance is being billed for the transport. These require documentation of additional patient demographics, treatment, and appropriate signatures.

• Donor Transport: Used for all donor-related transports, regardless of the team or mode of transport.

A complete transport may require more than one chart type.

In addition to the information provided by Comm Center, the following information is required:

HALF CHART:

• Flight Team

• Response Mode to Scene

• Transport Mode from Scene

• On-Scene Odometer

• Destination Odometer

• Short narrative

• Signature of EMT

FULL CHART:

• Flight Team

• Response Mode to Scene

• Transport Mode from Scene

• On-Scene Odometer

• Destination Odometer

• Patient Date of Birth

• Patient address and phone #

• Procedures during transport

• Medications during transport

• Detailed Narrative

• Signature of EMT

• Completion of ALS Form

• Completion of Signature Form

DONOR TRANSPORT:

• Transport Type

• Response Mode to Scene

• Transport Mode from Scene

• On-Scene Odometer

• Destination Odometer

• Short narrative

• Expense report

• Signature of OTS/EMT

• **Chain of custody information for “Organ Only” calls.

REQUIRED PAPERWORK:

The following paperwork is required for each FULL CHART:

• Sending Facility Face Sheet

• Receiving Facility Face Sheet

• Completed ALS Form

• Completed Signature Page

• Attach any additional paperwork provided by the flight team as it can be helpful to the billing team.

  
  

VERIFICATION OF INFORMATION:

Review the prepopulated information from Comm Center to ensure that is correct. Sometimes, the information provided to Comm Center by callers is incorrect. Confirm the following information:

• Flight Team name

• Spelling of patient’s first and last name

• Patient age/date of birth/gender

  
  

Notify Comm Center of any required changes.

EXPLANATION OF ALS FORM:

The ALS form is an important part of our documentation. This form assists in gathering pertinent information and is proof that the patient was attended to by a high-level provider.

The shaded area at the top of the form should be completed by the Flight Team.

Ensure the team has provided their first and last names.

The Medications and Interventions section can be completed by the EMT or the Flight Team, however, the EMT shall verify that the information is correct.

Pay attention to titration. Titration of some medications may elevate them from ALS to Critical Care.

EXPLANATION OF SIGNATURE PAGE:

The signature page is a critical component for billing purposes.

Section 1-Patient Signature:

• If the patient is over 18 years old and competent, they sign Section 1.

• If the patient is a minor child, the parent or legal guardian signs Section 1.

  • Indicate the relationship of the signer to the patient.

    
    

Section 2-Authorized Representative:

If the patient is not competent to sign, an Authorized Representative signs Section 2. The options for who sign this section appear in order of preference. You MUST include a SPECIFIC reason that the patient is unable to sign. “Weakness” is not acceptable.

Section 3-Medical Necessity:

This section should be completed and signed by the receiving RN, Physician, PA, NP or Case Manager. For reverse transports, the sending RN, Physician, PA, NP or Case Manager signs. All fields in this section must be completed.

The Flight Nurse cannot sign this section.

To be considered “Bed Confined” the patient must meet ALL the criteria.

1) Unable to get up from bed without assistance; AND

2) Unable to walk; AND

3) Unable to sit in a chair or wheelchair.

NOTICE OF PRIVACY PRACTICES (NPP):

We are required by law to provide a copy of the NPP to the patient. You do not need to hand this document directly to the patient. It is acceptable to give it to the patient’s representative, leave it with the patient’s belongings, or in a conspicuous place near the patient.

ELEMENTS OF A GOOD CHART:

Accurate and complete patient documentation is essential for several reasons: it protects you and the company legally, ensures continuity of patient care, provides a permanent medical record, and supports accurate billing.

Your goal is to create a chart that is both thorough and precise - painting a clear, detailed picture of the patient and the care provided. Think of it as telling the story of the call. Anyone reading your chart should be able to understand exactly what happened, even if they weren’t there.

Remember, you are the only member of our team who actually saw the patient and was present for the transport. We rely on you to capture and communicate that information.

NARRATIVE DETAILS:

When writing your narrative, it’s crucial to include certain key elements. For instance, if you’re dealing with a car crash or any traumatic injury, make sure to note the approximate time and date the incident occurred. For traumatic injuries, it is also important to be specific about the location and degree of injury. Rather than documenting that the patient had a “burn to the right arm”, documenting that the patient had a “second degree burn to the right forearm” paints a clearer picture of the injury.

For medical events, we also need to be precise in describing symptoms. Avoid using vague terms like "stroke-like" or "flu-like symptoms." Instead, specify exactly what symptoms are present, such as unilateral weakness, slurred speech, fever, cough, vomiting, etc. There MUST be at least one symptom noted in the narrative.

Ensure the following details are included in the narrative:

Patient Demographics

• Always begin with the patient’s age and gender.

• Confirm these details, as initial reports may be incorrect. Age is particularly important for billing and for locating patient records if multiple patients share the same name.

Medical History & Presenting Problem

• Include relevant medical history as it pertains to the transport.

• Document the primary reason for the transport (chief complaint and/or diagnosis).

• Describe the patient’s symptoms.

Interventions and Treatments

• Record all treatments provided, including medications, oxygen, and any other interventions.

• Oxygen use must be documented on both the ALS form and the EPCR (Electronic Patient Care Report).

See APPENDIX D for additional guidance on charting.

PAPERWORK PREPARATION/SUBMISSION

All paperwork must be scanned into the ePCR in the following order:

1. ALS Form

2. Signature Page

3. Sending Face sheet

4. Receiving Face sheet

5. Any other documents, such as:

   1. Signed Transfer Form or Physician Certification Statement (PCS)

   2. Copies of insurance cards/ID

Following completion of the ePCR, submit hard copies of paperwork to Comm Center for review. If at a remote base, place paperwork in the secure lockbox and notify Comm Center that your ePCR is complete.