Transcript Writing a PCR

A basic approach to
PCR REPORTS
Robby Latta
EMS Instructor / Training Officer
STILWELL 1EMS
Why do we have a PreHospital Care Report
• It was developed by a
committee of EMS providers
and administrators assembled
from across the state for the
purpose of establishing a
statewide EMS data system
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So…what is it?
The PCR is:
• a medical record
– the form becomes part of the
patient record and allows for
continuity of care
• a legal document
• it’s a way for the prehospital care
providers to prove what treatment
he/she gave
• a standardized record
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When to use a PCR
• A PCR should be filled out for
every call, including
emergencies, fire standbys,
mutual aid standbys, etc.
• If you were dispatched for a
call a PCR needs to be filled
out even if you were cancelled
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Parts of a PCR
A PCR has three copies to it.
• The white copy is retained by
the agency
• The yellow copy is used for
statewide data collection
• The pink copy is retained by
the hospital for the patient’s
record
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Writing a PCR
• SOAP
•
•
•
•
Subjective
Objective
Assessment
Plan
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Subjective
• What the
patient told
you.
• For example….
Patient states
that she was
walking down
the street and
walked into the
light pole.
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Objective
• What you see
• For example….
Upon arrival
found patient
lying on ground
next to light
pole in
apparent
distress
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Assessment
• What you found • For
wrong with the
example…..
patient during
Upon PE- pt
your
A & 0 x’s 4,
assessment
PERRL,LSCTA
bilaterally.
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Plan
• What you plan • For
on doing for the
example…..
patient
Patient placed
on 10 LPM 02
via NRBM.
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CHART method
•
•
•
•
•
C= Cx or chief complaint (c/c)
H= Hx or History
A= Ax or Assessment
R= Rx or Treatment
T= Tx or Transport
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CHART method
• Cx or chief complaint (c/c) is
what the patient initially called
the ambulance for. Some EMTs
write the actual pt’s words in
quotes. Such as- ‘pt c/o “ pain
in his stomach”.’ Other EMTs
prefer to write the c/c
objectively, such as- ‘pt c/c
SSCP w/ DOE.’
• Example on following slide….
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CHART method
• Cx- c/c is pt ‘thinks’ he’s
“having a heart attack”.
• Or
• Cx- c/c is SSCP w/ DOE; R/O
AMI .
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CHART method
• Hx or History includes the pt’s
Past Medical History (PMH)
and the History of Present
Illness (HPI).
• For example you might see..
• Hx- Pt has Hx of COPD, CHF,
and ESRD. Pt has NKDA. Pt
has had CP x’s 3 hours, not
relieved by rest or NTG. Pt has
NTG Rx prn for CP and stated
he “ took one about an hour
ago” PTAA, with no relief.
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CHART method
• Ax or Assessment include all
findings when you assess the
pt your LOC, V/S, and any
physical findings in you
assessment should be
documented here.
• For Example see following
slide…..
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CHART method
• Ax- UAA found pt A&O x’s 4,
sitting on couch, c/o “dull” CP
of 8 on 1/10 scale, radiating to
left arm and lower jaw. Obtain
baseline v/s; P-112 and
regular, R-20 and labored, B/P
160/98, SpO2= 92%@RA.
Lung sounds have rales
bilaterally, Pupils PEARL, PMS
√ good x’s 4, Skin is cool
clammy and pale. Note +2
pitting edema in lower ext,
everything else unremarkable.
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CHART method
• Rx or Treatment can be
confusing, because in all other
medical documentation Rx
means “prescription” and Tx
means “treatment”. However
for the CHART method Rx
means “treatment”. In this
subheading you may list all
interventions done by you on
behalf of the patient.
• For example see following
slide……
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CHART method
• Rx- Place pt on cot in POC,
place pt on O2 @ 12 lpm NRB,
Admin ASA 81 mg x’s 2, Assist
pt with his NTG (second dose
@ 1554) .04 mg SL, est IV in L
hand with 18 ga cath with NS &
10 gtt set, @ 250 ml hr.
Perform Blood Draw, and a
obtain a Chemstrip = 215.
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CHART method
• Tx or Transport is all things to
do with pt transport including
destination, transport status,
and any incidents that happen
while enroute to the medical
facility. This includes your
ongoing assessment and
treatment evaluation.
• For example see following
slide…….
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CHART method
• Tx- Transport non-emg to
SMH. Enroute monitor v/s q5m
note B/P↓ to 130/88, CP↓ to 5
on 1/10 scale, P↓ to 100, and
SpO2 ↑99%@12Lpm NRB.
Trending v/s listed below.
Continue to monitor v/s while
enroute noting no other ∆’s.
TOT ER staff upon arrival.
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CHART method
• Put all those together and you
get something like this……
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CHART method
• This method is by no means
the only, or even the best way,
to write a PCR narrative.
However, it is a simple way,
and is easily understood. The
“BEST” way to write your
narrative, is whatever works
best for you..
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PCR Narratives
• Most EMT’s develop their own
“style” for writing run sheets,
and stick to it. As long as it
works for you and you
document well, it makes no
difference how you write it.
• Remember your narrative
should “paint a picture” of the
entire call from start to finish.
Anyone who reads it should
have no trouble as to
deciphering what exactly
happened.
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and
Remember…
If you didn’t
write it…..
You didn’t
do it!
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What to write on a PCR
• Anything that
• Anything
you did for the
unusual with
patient
the call
• Anything you
• Who started
found during
care before you
the assessment
got there
• How you found • If you did it, you
the patient
should write it.
• Where you left
the patient
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What not to write on a
PCR
• Any foul or
• Don’t write on
objectionable
anything that
language
you have lying
on top of a
• Anything that
PCR because it
could be
will copy onto
considered libel
the PCR
– for example:
because of the
“He was drunk”
carbon paper.
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How do I word
objectionable phrases
into stuff I can use
• “He was drunk”
• How do you
know that the
patient was
drunk. Could
have had an
Altered LOC
due to a head
injury, a
diabetic
emergency, a
stroke, etc.
• “Patient had an
odor of
intoxicating
substance on
breath”
• “Patient admits
to drinking 2 40
ounce bottles
of beer.”
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How do I word
objectionable phrases
into stuff I can use
• “He was high”
• How do you
know that the
patient was
high. Could
have had an
Altered LOC
due to a head
injury, a
diabetic
emergency, a
stroke, etc.
• “Patient admits to
using illicit
substances”
• “Patient unable to
stand on his own
without staggering
and has auditory
and visual
hallucinations”
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Grammar and Spelling
• Make sure
that your
grammar and
spelling are
correct. It will
make a big
difference to
people
reading it,
including
lawyers!!
• If you’re not
careful with your
spelling, how
careful were you
with your patient
care.
• Your PCR is full
of fun-filled
words.
Remember, most
of what you need
to write is
already on your
PCR
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Going to court
• Better be sure
that your
documentation
was wellwritten
• Don’t
– Most EMS
personnel don’t
go to court until
4-5 years after
the call was
done.
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CQI
What is it and why do we
have it?
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Continuous Quality
Improvement
• We have it
because we
have it.
According to
NYS DOH
Policy 96-01.
• It makes us
better EMT’s
and
Paramedics
• We learn things
that we could
do differently
and more
importantly
things that we
shouldn’t do.
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Some aspects of CQI
• Individual PCR
Reviews
• Drills and
Training
• Call Audits
• CEU classes
• Etc,
• A system of
continuous review
and checks and
balances to
ensure that proper
care was given for
the appropriate
diagnosis.
• Provides for
interaction with a
Medical Control
Physician and
other health care
affiliates.
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The End
• Any questions…
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