Writing a PCR

 

Why do we have a Patient 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

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

 

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

 

Writing a PCR – the Narrative

CHART

Chief Complaint

History

Allergies

Rx-Treatment

Transport

Chief Complaint

This is where the patient’s chief complaint should be noted. Remember that chief complaint and reason for dispatch are not always the same. Example: MVC is a reason for dispatch but should not be the chief complaint. The complaint should be phrased in such a way as “arrived on scene to find this ____ yo male  complaining of ____ or Arrived to find this ___ yo femalewith cieif complaint of ___.

You can use patient statements in the chief complaint just as you would under the subjective heading of SOAP notes. Remember that anything the patient states should be placed in quotation marks..

History

This mainly deals with the history of the present illness or injury(HPI). This portion of the Report should immediately follow the chief complaint. HPI should include such information as time of onset, duration of signs & symptoms (S/S), anything that provokes or relieves the S/S, prior onset of S/S etc. The history should also support any diagnosis that has been made. Does the patient have a Hx of hypertension, MI, Diabetes, etc.

History does not need to include things that have no relevance as in the patient having an appendectomy 12 years ago.    

Assessment

What was the result of your exam of patient during your assessment. Neurological status, Level of Consciousness (LOC), pupils, movement of extremities, etc. This should include patients communication ability, Skin condition, pedal edema, lung fields, etc. DCAP-BTLS, Head to toe exam. If you have the patient for more than 20 minutes there should be more than one assessment on the patient!

Rx- Treatment

This is where you document your treatment and response of the patient to your treatment of the patient. All treatment should be documented both successful and unsuccessful. If you use check boxes to document part of the treatment make sure you reference it in your comments. Many times reviewers will not look at the check boxes unless there is a reference to it in the comments. Please note significant changes in the patient’s condition after treatment are rendered. Example: “pain decreased to 5/10 from 7/10 after NTG X 2 given.” Be meticulous about documenting airway procedures and always document patency of airways prior to turning over patient care to others.

Transport

This is where any other changes would be placed in the reun report. If anything unusual occurred during the transport of the patient. If for some reason there was an alteration in protocol for some reason this should be documented thoroughly. You should also report whom the care of the patient was turned over to being as specific as possible.

Remember, If you didn’t write it…..

You didn’t do it!

 

What to write on a PCR

Anything that you did for the patient

Anything you found during the assessment

How you found the patient

Where you left the patient

Anything unusual with the call

Who started care before you got there

If you did it, you should write it.

 

What not to write on a PCR

Any foul or objectionable language

Any 10 Codes or other radio codes

Anything that could be considered libel

for example: "He was drunk"

 

How do I word objectionable phrases into stuff I can use

"He was drunk" = "Patient had an odor of intoxicating substance on breath"

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.

If the patient tells you he was drinking, document factually: "Patient admits to drinking 2  40 ounce bottles of beer."

 

How do I word objectionable phrases into stuff I can use

"He was high" = "Patient unable to stand on his own without staggering and has auditory and visual hallucinations".

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.

If the patient tells you he was drinking, document factually: "Patient admits to using illicit substances".

 

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.

 

Going to court

Better be sure that your documentation was well-written

Most EMS personnel don’t go to court until 4-5 years after the call was done - Good documentation is important!!!

 

The End

 Revision 12/6/09

 

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