PW&W’s Stark and Johnson provide legal insight into PCRs

This episode of EMS One-Stop With Rob Lawrence is brought to you by Lexipol, the experts in policy, training, wellness support and grants assistance for first responders and government leaders. To learn more, visit lexipol.com.

Page, Wolfberg & Wirth was asked by the National EMS Information System (NEMSIS) Technical Assistance Center (TAC) to research frequently asked questions related to data in EMS patient care reports. PW&W analyzed these questions under applicable laws and guidance, and developed general answers and best practices contained in the new publication, “Patient Care Report Data QuickGuide - FAQs on owning, amending, retaining and sharing patient care report data.”

In this week’s EMS One-Stop, available in both video and audio versions, Host Rob Lawrence speaks with the PW&W authors of the project, Ryan Stark, managing partner, and Steve Johnson, director of reimbursement consulting. They discuss the guide, why it’s needed, and the major FAQs and misconceptions about PCRs.

The guide is broken down into four key areas of FAQs:

1. PCRs’ legal status
2. Amending PCRs
3. PCR retention
4. Transferring PCR data

Top quotes from this episode

“I would much rather defend an organization who regularly goes through a quality assurance process, whereby they make the provider and hold them responsible for the accuracy and completeness of the record.” — Ryan Stark

“Others may say, we see a lot of amendments to your records. The answer is ‘yes, that’s because we care about getting it right’ – that’s the mantra of our organization.” — Ryan Stark

“One of the things behind the importance of documentation is that it doesn’t live in a vacuum. We are in a day and age where it’s going to follow the patient for their lifetime, so you may have a rehab facility that wants to consult the medical record to determine the mechanism of injury or how the injury occurred and the only person [that knows that] is the EMS practitioner.” — Ryan Stark

“Long gone are the days where we can give you a quick ticket, passing along the information to the receiving facility. Now we are marrying up records, electronic health exchanges and other mechanisms and the genesis of all this starts with the original call.” — Steve Johnson

“Everyone should sign the patient care report. Why? Because everyone was a function of providing that particular service and we get a lot of pushback and they say ‘well now I’m legally responsible for everything that happened,’ and that’s not what the law says. The law says, for what you did, you are responsible for what you did and what you didn’t do when you had a legal duty to do something or withhold doing something because it was contraindicated. All that indicates is that yes, I reviewed it and to the best of my knowledge it’s true and accurate.” — Ryan Stark

“The law will impose liability where it lands. Just because you’ve signed that particular patient care report, doesn’t mean you’re responsible for all the interventions and everything that I outlined in there, it would be whoever performed or withheld those interventions that would be responsible within the scope of practice.” — Ryan Stark

Episode contents

1:09 – Introductions

1:30 – PWW history

3:30 – Introducing the PCR Data QuickGuide

4:20 – The circle of life of a PCR 

11:00 – NEMSIS data/research license and EMS by the numbers

13:20 – Who owns PCR data

15:50 – Signatures! And legal responsibility

17:40 – Accuracy of documentation to defend your actions

18:30 – Why does the driver have to sign?

20:00 – Amending PCRs: When and why

22:33 – Who do you tell if a record is amended?

24:30 – Can your state request you to amend your PCR?

27:30 – How long should we keep documents?

30:50 – When an agency closes down or merges

33:30 – Body-worn camera content

35:30 – Transferring paper records to digital

37:15 – Bi-directional data and HIE – responsibilities

40:00 – Final thoughts

Additional resources

• The PCR Data QuickGuide is available now, and we encourage all EMS professionals to download their copies and gain a deeper understanding of PCR data best practices. To download the guide, please follow the link:
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