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6. Chief complaint at time of transport; <br /> 7. Past Medical History; <br /> 8. Narrative - Thorough description of the patient encounter at the time of transport; <br /> 9. Vital signs; <br /> 10. Treatment rendered (e.g. oxygen, EKG, drugs); <br /> 11. Loaded miles using trip counter/Mapping mileage (Medicare requires mileage be documented to the nearest <br /> tenth of a mile <br /> 12. Field Provider signatures (Attendant and Driver); and <br /> 13. Patient signature or alternate signature/documentation; <br /> B. There are often other forms of medical documentation that Field Providers receive, such as PCS forms and <br /> hospital and nursing home face sheets. All additional information regarding the patient's medical condition <br /> must be attached to the PCR before it is sent to the Billing Contractor, <br /> C. The PCR should be completed by the end of the shift during which the transport occurred, must contain <br /> accurate information, and must be received by the Dispatch Office during the assigned shift. Addendums must <br /> be completed within the same timeframes, as applicable. <br /> IV. DOCUMENTATION <br /> Accurate and complete documentation of the entire patient encounter is extremely important to comply with <br /> health care rules and regulations. A PCR should contain the items listed in Section III., along with the <br /> following: <br /> A. Describe the patient's medical condition at the time of transport and the reason for transport. <br /> B. Describe how the patient was found (e.g. in bed, in a wheelchair, standing,unconscious); <br /> C. Describe how the patient got to the stretcher and ambulance (e.g. walked with assistance, lifted by draw <br /> sheet); <br /> D. Use only acceptable abbreviations in completing the PCR. <br /> E. Document the patient's physical and mental assessment and other pertinent findings. Explain why the patient <br /> could or could not go by other means (e.g. comatose, severe lower extremity contractures, why patient could <br /> not self-regulate oxygen during transport, required restraints, physical limitations and deficits, etc.). These are <br /> merely a few examples and are not all inclusive. <br /> F. Paint an accurate picture of the entire patient encounter. <br /> V. PATIENT SIGNATURES <br /> Field Providers are responsible for obtaining the patient's signature on the Patient Signature Form, as specified <br /> in NSMT 's Policy on Patient Signatures.. <br /> 42 <br />