Transcript Writing a PCR

Writing a
PCR
Nikhil Natarajan, REMT-P
Quality Improvement Coordinator
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Beacon Volunteer Ambulance Corps.
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 PEyour
CAOx3,
assessment
PERRL, Lungs
clear = bilat.,
etc., etc.
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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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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
AMS 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
AMS 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
• A system of
checks and
balances to
ensure that proper
care was given for
the appropriate
diagnosis
• Provides for
interaction with a
Medical Control
Physician
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The End
• Any questions…
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