Transcript Review of PCR / PCR Writing

Review of PCR / PCR Writing
Ken L. Hendricks, Ed.S, PI, NREMTP
and Rick Hines EMT-P, PI
February 2009
PCR Purpose
• Medical Record
• Legal Document
• Protection
• Justification
• Billing
• QI
• Training
• Research
A Good PCR Requires . . .
 Accuracy
 Just the Facts
 Completeness
 Fill every line in
 Legibility
 Sloppy Report = Sloppy Care
 Free of Extraneous Information
 Don’t Label Patients
Strategies for a First-Rate PCR
• Write the PCR soon as possible.
• Use more than 1 page if needed
• Extra Careful on Subjective Issues
Documentation – what you think (High
probability of law suits)
Writing an Effective Narrative
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Learn a System
Be Consistent
Think Before you Write
Spell Check
Take your Time
Re-Read &Proof Read the Narrative
Use Accepted Abbreviations/Terms
What Not to Write
• Any foul or objectionable language.
• Anything that could be considered
libel: for ex.: “He was drunk”
• Don’t write on anything that you
have lying on top of a PCR. It will
be copied to the PCR.
Suggestions I
1) Patients are no longer drunk, intoxicated, or
inebriated. Please document them as "Alcoholically
Gifted".
2) You can no longer refer to patients as homeless,
document their address as "Domicile Challenged"
3) Pt's do not have hallucinations from drug abuse they
have "pharmaceutically enhanced vision"
4) There are no more RoS PCR's, patients refusing
treatment are now "seeking alternative treatments"
5) Patients are no longer combative they "Physically
assert themselves"
PCR Models
• SOAP
• CHART
• Ken’s
How Do I Write a First-Rate PCR ?
• Subjective
• SOAP
•Objective
•Assessment
•Plan
Subjective
• What the
Patient
told you.
• Example …..
Pt advised she was leaving after eating
and slipped in water falling
Objective
• Example ….
• What You
See
UOA Pt. Supine on the floor w/ a
waitress holding pressure to the
lower leg with a shirt and
moderate amount of blood on the
floor
Assessment
• What was
found
wrong with
the patient
during
assessment
• Example ….
Pt P/W/D, Pearl, Ls Clear = Bilat x 4,
…………Pt has a open Fx to R
Lower Leg
Plan
• What are
you planning
on doing for
the patient
• Example . . . .
02 via Cannula at 3 lpm ….
Applied multiple 4x4 to area w/ 2
rolls of kerlex.
Ouch! This will leave a mark!
The C.H.A.R.T. Method
• C = Chief
Complaint
Example
Pt c/o pain and swelling to R lower
Leg
H = History
• History of
what
happened and
past medical
history
Example..
Medical History: Diabetes,
Thyroid problems… to include
meds and allergies.
History of incident:
Pt. advised she was leaving after
eating………
A = Assessment
• What you
find during
your
• Exam
Example …
……Pt has a gaping laceration to R
leg from Mid-lower R Leg extending
downward into middle of R
foot……….
R= Responses
• The
responses
the patient
has to your
treatment.
Example ……
After oxygen the patient
skin color start to return to
normal…….
T = Treatment
• What
treatment
you
administered
to the
patient.
Example ….
02 Cannula at 3 LPM……….
Remember . . .
If you Didn’t Write It…..
You Didn’t Do It !!!
Ken’s Method
• C/C . . Chief Complaint
• HPI . . History of the Present Illness
5 Step
Process • Exam . . Signs & Symptoms
• Rx . . Treatment
• Tx . . Transport
C/C . . Chief Complaint
• Chief Complaint
• What the patient’s tells you why
they called you, or, if the patient
can not, what the family tells you
or if neither is available, what you
see.
HPI . . History of the Present Illness
• History of Present Illness or Injury
• What led up to the call for EMS
• Brief description of what caused
the Chief Complaint
• Events before EMS arrived
pertaining to the Chief Complaint
PE . . Exam
• Physical Exam
• What your Senses Tell You
• Signs and Symptoms of Patient
• Organized Fashion
• Rapid or Focused
• Complete
• O-P-Q-R-S-T: AVPU: SAMPLE
Rx . . Treatment
• Interventions . . What Aide and Comfort
the Patient Received . .
• Specifics of Therapies Administered
• Amounts, Times, Medics, etc.
• Responses to Treatment.
• Standing Orders . . Protocols
• Treatment by 1st Responders (what & who)
Tx . . Transport
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Position of Patient
Surface: LSB, Cot, Secured (how or if)
Any Changes Enroute
Radio Contacts: IHERN-Med Channel
Disposition of the Patient
Signature of Person Accepting Patient
Special Information
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Long Scene Time ?
Obese patient hard to move ?
Long extrication ?
Any other pertinent information ?
ABC’s of PCRs
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Accurate and Honest
Brief but Thorough
Concise but Clear
Consistent
Signature Required
Remember . . .
• You can never write to much
information…….but you can write
to little of information.
• Average time frame for a lawsuit or
court case is 3-4 years….can you
remember ?
Example of Ken’s Method . . CVA
C/C: Slurred Speech
HPI: Pt. was found by family this morning with slurred speech. Family could not contact pt. this
morning so they came to check on him. Family states pt. was fine last evening playing cards. About 10
minutes ago noticed pt. was slurring words. Patient has had some TIA over the past year.
EXAM: O/A found an elderly female. pt seated on the couch Alert, slightly Confused, Responsive.
See above for V/S. FLAGS:
Face; mouth drop to the R, slurred speech; unable to show front teeth
Legs: R drifts to R;
Arms; R drifts to R; limited strength R, unable to touch R fingers to thumb
Grips; weak to R,
Speech; slurred
CMSx4 present, Negative for DCAP-BTLS, Bilateral/= Chest Expansion, Negative JVD, Negative
for Respiratory S et S, unable to stand without assistance
Rx: Pt. assessment completed, 4L 02/NC, SL c 18CON by KH to L wrist, protected R side of pt
with pillows/blankets on cot
Tx: Pt. assisted to cot. Secured on cot. Pt supine on cot with a 30 degree head elevation. O2
continues as above. V/S re-taken. Full exam completed. Speech now seems more clear. Med Channel
2 to Luth with pt. information - Stroke Study Candidate. O/A at Luth, pt. released to RNs without
further. PCR completed and signed by RN.
KH452
NREMTP
Suggestions II
1) Patients are not emotionally disturbed, they are able to
"view alternate realities", or "view reality differently“
2) Patients who are obese are now 'mass gifted'
3)The patient didn't die, he failed to maximize his life's
potential.
4)It is not a broken arm, it is a Painful swollen deformed
extremity
5)Our patients are no longer juvenile, we actually have a reg
that defines them as age deficient.
Suggestions II
If you get this far, make up one of
your own submit it to me
and get some extra credit.
thanks