Sunday, April 18, 2021

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Data Collection

Data Collection
Pursuant to the Rules & Regulations promulgating the EMS System Act of Pennsylvania, "§ 1021.41. EMS agencies shall collect, maintain and electronically report complete, accurate and reliable patient data and other information as solicited on the EMS PCR form for calls for assistance in the format prescribed by the Department. An EMS agency shall file the report for calls to which it responds that result in EMS being provided.  The report shall be made by completing an EMS PCR within the time prescribed by the EMS agency’s written policies, no later than 72 hours after the EMS agency concludes patient care, and then submitting it, within 30 days, to the regional EMS council that is assigned responsibilities for the region in which the EMS agency is licensed.” 

Below are some answers to commonly asked questions related to Data Collection:


 I'm a BLS Service, must I forward a copy of the tripsheet (patient care report) to the receiving facility, even if ALS is on board?
"The EMS agency shall provide the completed EMS PCR to the receiving facility to which the patient was transported within 72 hoursafter the EMS agency concluded patient care."
  • Williamsport Hospital & Medical Center - 570-321-2265 (Please note this is a NEW #)
  • Muncy Valley Hospital - 570-546-4138
  • Jersey Shore Hospital - 570-398-1850
  • Soldiers & Sailors Memorial Hospital - 570-724-6541
  • Evangelical Community Hospital - 570-522-4740
  • Geisinger Medical Center - 570-271-7165  (Please note corrected #) Can also email to secure address: 
  • Bloomsburg Hospital - 570-387-2245
  • Memorial Hospital (Towanda) - 570-268-2244
  • Robert Packer Hospital - 570-887-4939
  • Troy Hospital - 570-297-3106
  • Lock Haven Hospital - 570-893-5023 
This is required of all EMS Agencies completing a patient care report, ALS, BLS, or Helicopter. The tripsheet then becomes a part of a patient's permanent medical record.

What if a helicopter transports my patient?
The same requirement exists to provide a copy of the tripsheet to the facility who ultimately receives your patient.  Below are the fax numbers to the most frequently utilized aircraft by LTS Providers:
    • Geisinger Medical Center (LifeFlight)  -  570-271-7165  (Affiliate #47700)
    • Robert Packer Hospital  (Guthrie Air)  -  570-882-4939   (Affiliate #08013)
    • Hershey Medical Center (LifeLion)      -  717-531-3878    (Affiliate#22091)

How long must I keep copies of patient care reports?
"The ambulance service shall retain a copy of the EMS patient care report for a minimum of 7 years."

The Pennsylvania Department of Health distributes a list of approve data collection vendors (revised 7/2015).  Tripsheets must be completed on forms provided by the Department of Health through the Regional EMS Councils or on DOH approved programs.

As of 2012, the PA Department of Health adopted new guidelines for Quick Response Services (QRS) with a separate form for data collection that is maintained at the service for inspection. 

 As a CQI coordinator for my service I notice that documentation on patient care reports could be improved.  Any hints??
Click HERE for some guidlines on documenting patient care on the tripsheet.
The LTS EMS Council staff is also available to provide on-site support for documentation.  Please contact the council to schedule a training session.  Invite your neighboring companies!  Con.ed. credit may be available.

What must be included in a Patient Refusal??
A complete patient assessment should be completed on all patients who wish to refuse treatment/transport.  The LTS EMS Council provides Patient Refusal forms free of charge for all services in Lycoming, Tioga, and Sullivan Counties. Form should be completed on all patients refusing treatment and signed by the patient.  Remember, medical command should be contacted in certain circumstances (outlined on the form) and in those cases where patients may wish to refuse and the EMS Crew does not believe it is in the patient's best interest to do so, you can have medical command speak directly to the patient.   (See PA Protocol #111 - Refusal of Treatment/Transport.)

Common Medical Abbreviations for Tripsheets

ABG Arterial blood gas
A* Before
a.c. Before meals
ADL Activities of daily living
ad lib As desired
Afib Atrial fibrillation
AFL Atrial flutter
AIDS Acquired immunodeficiency syndrome
AP Anteroposterior
A&P Anterior and posterior
AQ Water
ARDS Adult respiratory distress syndrome
ASHD Atherosclerotic heart disease
b.i.d. Twice a day
BLS Basic life support
BP Blood pressure
bpm Beats per minute
BUN Blood urea nitrogen
BX, Bx Biopsy
C Celsius, centigrade, complement
c* With
Ca Calcium
CA, Ca, ca Cancer, carcinoma
CAB Coronary artery bypass
CAD Coronary artery disease
caps Capsules
CBC Complete blood count
CC, C.C. Chief complaint
cc Cubic centimeter
CCU Coronary care unit
CHF Congestive heart failure
CK Creatine kinase
Cl Chloride, chlorine
cm Centimeter
CNS Central nervous system
CO Carbon monoxide, cardiac output
CO2 Carbon dioxide
COMP Compound
COPD Chronic obstructive pulmonary disease
CPK Creatine phosphokinase
CPR Cardiopulmonary resuscitation
CSF Cerebrospinal fluid
CVA Cerebrovascular accident
D&C Dilatation and curettage
DM Diabetes mellitus
DNA Deoxyribonucleic acid
DO Doctor of osteopathy
DX, Dx, dx Diagnosis
ECG Electrocardiogram
ED Emergency department
EEG Electroencephalogram
ENT Ear, nose, and throat

ft Foot, feet, (measure)
g, gm Gram
GI Gastrointestinal
GP General practitioner
gt, gtt Drop, drops
GU Genitourinary
GYN, gyn Gynecology
Hb Hemoglobin
HCT Hematocrit
Hg Mercury
Hgb Hemoglobin
HGH Human growth hormone
HI Hemagglutination inhibition
HLA Human leukocyte antigen
HR Heart rate
Hr Hour
h.s. At bedtime, hour of sleep
Hx History
Hz Hertz (cycles per second)
IABP Intra-aortic balloon pump
ICF Intracellular fluid
ICU Intensive care unit
I.M. Intramuscular
I.V. Intravenous
IVP Intravenous pyelogram
K Potassium
kg kilogram
LAD Left anterior descending (coronary artery)
lb Pound
LBBB Left bundle branch block
LDL Low-density lopoprotein
LUQ Left upper quadrant
MD Medical doctor, muscular dystrophy
mEq Millequivalent
Mg Magnesium
mg Milligram
MI Myocardial infarction
ml Milliliter
mm Millimeter
MRI Magnetic resonance imaging
MS Multiple sclerosis, morphine sulfate
N Nitrogen, normal (strength of solution)
Na Sodium
NaCl Sodium chloride
NGT Nasogastric tube
NPO Nothing by mouth
Ob-GYN Obstetrics and gynecology
OTC Over the counter (a drug that can be obtained without a prescription)
oz Ounce
PaCO2 Partial pressure of carbon dioxide in arterial blood
PaO2 Partial pressure of oxygen in arterial blood
p.c. After meals
PCO2 Partial pressure of carbon dioxide
PO2 Partial pressure of oxygen
peds Pediatrics
PERRL Puplis equal, round, react to ligh
PID Pelvic inflammatory disease
PKU Phenylketonuria
PMS Premenstrual syndrome
P.O. By mouth
PPD Purified protein derivative (of tuberculin)
ppm Parts per million
p.r.n. As needed, whenever necessary
psi Pounds per square inch
PT Physical therapy
PVC Premature ventricular contraction
q Every
q.d. Every day
q.h. Every hour
q2h Every 2 hours
q4h Every 4 hours
q.i.d. Four times a day
RLQ Right lower quadrant
RN Registered nurse
RNA Ribonucleic acid
R/O Rule out
ROM Range of motion (of joint)
RUQ Right uper quadrant
Rx Prescription
s* Without
SaO2 Systemic arterial oxygen saturation (%)
S.C., SQ, subq Subcutaneous
SIDS Sudden infant death syndrome
SOB Short of breath
S&S Signs and symptoms
ss* One-half
stat Immediately
STD Sexually transmitted disease
Tabs Tablets
TB Tuberculosis
temp. Temperature
TIA Transient ischemic attach
t.i.d. Three times a day
TMJ Temporomandibular joint
TPR Temperature, pulse, respirations
tsp Teaspoon
UA Urinalysis
URI Upper respiratory infection
Vfib Ventricular fibrillation
VS Vital signs
VT Ventricular tachycardia
UTI Urinary tract infection
WBC White blood cell

* abbreviations should have a line above the character or abbreviation


For more information contact:
Name:  William Miller
Title:  Regional EMS Field Coordinator
Office:  LTS EMS Council
Voice:  570-433-4461
Fax:  570-433-4435 FAX


Last Updated: 3/15/2021 2:02 PM
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