Important Notes
Transfers require complete patient charts. Just because a patient is on hospice or being transported from the ER to another facility does not mean they require any less thorough care or documentation. You are still expected to perform your own assessments, obtain vital signs, and gather a patient history just as you would on an emergent call.
Example
D: Medic 1 was dispatched for an interfacility transport from Hospital ER to a private residence for a hospice patient. Medic 1 responded non-emergent.
C/C: "I’m just tired and ready to go home."
Hx: EMS arrived at the hospital and was directed to the patient’s room by hospital staff. Upon arrival, EMS found the patient lying supine in the hospital bed, awake and in no apparent distress. Patient is an 82-year-old female currently on hospice care due to end-stage lung cancer. Hospital staff reported that the patient was being discharged home for comfort care. Upon introduction, the patient was alert and able to answer questions appropriately. Patient reported generalized weakness and fatigue but denied any acute pain at this time. Patient stated she has been experiencing increasing shortness of breath over the past several weeks, which has been managed with oxygen therapy. Patient denied any recent changes in symptoms. Patient is currently on oxygen via nasal cannula at 4 LPM. Patient reports a history of lung cancer and hypertension. Patient denies any known drug allergies. Patient is not on any medication at this time and advised that she no longer sees the point of it. Only current treatments that she will accept is oxygen therapy. No additional complaints were reported at this time.
Assessment: Patient is AxOx4 to person, place, time, and event with a GCS of 15. Airway is patent. Patient is able to speak in full sentences, though slightly fatigued. Breathing is adequate with mild increased work of breathing noted at baseline. Lung sounds are diminished bilaterally. Radial pulses are present and regular. Skin is warm, dry, and intact. No signs of trauma or external bleeding noted. Patient appears lethargic but stable. Oxygen is being administered via nasal cannula at 4 LPM.
Rx: No treatment provided by EMS. Patient was maintained on oxygen via nasal cannula at 4 LPM as prescribed. Vital signs were monitored throughout transport. Initial vital signs at bedside were: BP 147/96, PR 88, RR 20 slightly labored, SpO2 95% on 4 LPM via nasal cannula. Secondary vital signs prior to arrival at destination were: BP 139/92, PR 84, RR 20 slightly labored, SpO2 96% on 4 LPM via nasal cannula. Patient condition remained stable and unchanged throughout transport.
Transport: Patient was assisted from hospital bed to stretcher with a drawsheet pull x3. Patient was secured to stretcher with all appropriate straps and successfully loaded into the ambulance. Patient was transported non-emergent to private residence without incident in semi-Fowler’s position for comfort. Upon arrival, patient was moved from stretcher to home bed with assistance from family via drawsheet pull transfer x4. Report was given to receiving family member and hospice caregiver. All required signatures were obtained.
I: Hospice transport / end-stage lung cancer
Disclaimer: Everyone writes PCRs a little differently. As long as your information is placed in a section that makes sense, is documented in DCHARTI format, and you obtained all pertinent information, that is acceptable. PCRs should tell a story. If your PCR is subpoenaed one day, you should be able to remember that patient based on your report. If it isn't documented, it did not happen. Additionally, please ensure you follow all procedures for checking in to your shift, log all patient encounters before checking out, and complete all end-of-shift requirements prior to leaving the site.