PCR WRITING AND DOCUMENTATION

PCR WRITING AND DOCUMENTATION

Requirements Musts/Omissions Documentation Subjective v.

Objective Assessments Comments Redundancy

Acceptable / Authorized Medical Abbreviations

GCS RMA’s / Forms Rear of PCR Telling a Story

Objectives of this class

WHAT IS A PCR?

◦Pre-hospital – These are issues and conditions the ED staff can’t see and don’t know about. Important to document. Accidents – condition of car, position of patient Homes – condition, temperature, medical

devices Nursing facilities – need I say more

Pre-hospital Care Report

◦Care – Simple…What treatment did you provide to the patient Again, if it’s not visible, the ED staff won’t know

what you did Self treatment prior to EMS arrival


◦Report – As by it’s very definition: (noun)

a usually detailed account or statement (transitive verb)

To relate the words or sense of To make a written record or summary of To give a formal or official account or statement

of


◦Report Examples

Book reports Accident reports Report cards Reporters


◦Report

◦ TELL A STORY

◦ RELAY INFORMATION


COMPONENTS OF THE PCR

Date (mm/dd/yr)

07/18/13

132186

Can be completed post call

05129 32420


Agency Name – BSBRA Dispatch Information

◦ Plain English – Chest Pain◦ EMD Code – 10D3

Call Location◦ As specific as possible◦ Address◦ “IFO”, “in vicinity of”, intersection, direction,

business name, etc. Location Code – 5154 (Islip Township)

◦ 5100 only if unsure



Times

◦ Must be filled in prior to leaving the hospital

◦ Call headquarters or MedCom if needed◦ Must correlate with vital signs





Name – Spell correctly◦ This is what is used at triage to get pt. into

the system Phone –

◦ should be an emergency contact, NOT the patient’s personal cell

DOB/Age – Again, be accurate◦ If you can’t do the math and figure out the

person’s age, ASK THEM SSN – Important for patient tracking


- Jose Diaz- Juan Martinez- Victor Rivera- Julio Gonzalez- Maria Sanchez

Michael Brown Susan Smith Tom Robinson Frank Williams Karen Jones



Physician◦ General Practitioner if possible◦ Can write in specialists too

Care in Progress on Arrival◦ Self explanatory◦ If possible, name and vehicle

Mechanism of Injury Fill in and Extrication required document Seat belt used accordingly



Use the words of the patient◦ “I fell and hurt my knee”◦ “I thought I was going to pass out”

Use the words of a witness◦ “He fell down and hit his head”◦ “She started shaking a lot”

Do NOT write diagnosis here◦ “Syncope”, “blunt trauma”, “diabetic”

If patient cannot or doesn’t make a statement:◦ None – pt unresponsive – pt AMS



Presenting problem◦ Fill in circle of ALL that apply

Cardiac related, Respiratory Distress, Pain, Other

Head injury, Fracture, Bleeding◦ Circle primary condition/incident

◦ Pain and Other – be specific L sided c/p radiating to jaw and L arm Nausea, dizziness, AMS



Fill in circle of all that apply Other: GERD, Vertigo, Gout, Anxiety, etc Allergies and Medications

◦ WRITE SMALL◦ DO NOT write up the side of the PCR◦ DO NOT use up entire assessment/comment

section if the pt. eats the pharmacy daily◦ Use continuation form◦ “See list” - unacceptable



Times MUST correlate with response times!!!!!

Respirations and Pulse◦ Rate and condition

Blood Pressure◦ “Palp” or “P” is acceptable – document!

LOC◦ How does the pt. respond based on stimuli◦ Alert does not mean oriented


◦ 1st set of v/s should be within 1st five minutes of patient contact – if not, document reason for delay Prolonged extrication, delayed pt. contact, pt.

agitation, etc.◦ Make every effort to obtain 2 sets of v/s,

especially if giving treatment – if only one set, document why


◦ GCS – Glasgow Coma Scale


◦Eye Opening (1-4)

Similar to LOC , but different



◦Verbal Response (1-5) Oriented Confused Inappropriate Words Incomprehensible Sounds None


◦Motor Response (1-6) Obeys Command Localizes Pain Withdraw (pain) Flexion (pain) Extension (pain) None


Glasgow Coma Scale◦For any sum other than 15 or 3, write

the individual numbers of each assessment above the total

◦Eye opening – spontaneous (4)◦Verbal Response – confused (4)◦Motor Response – obeys command (6)◦Total = 14


Pupils◦ Difference between R & L??◦ It’s okay if not assessed – document

Skin◦ Unremarkable means exactly that

CUPS◦ Critical◦ Unstable◦ Potentially Unstable◦ Stable



Treatment Given◦ Fill in circle to all that apply◦ Fill in all boxes and blank lines◦ “Other” section– PFA / ES not necessary

◦ Questions regarding specific treatments?


Subjective◦ Personal

perspective◦ Feelings, beliefs,

opinions, attitudes

◦ Existing in the mind

◦ Cannot be seen

Objective◦ Object◦ Something

tangible◦ Can be

seen/touched◦ Measurable fact

or evidence

Subjective vs. Objective

Subjective◦ What the pt. tells

you◦ Pain, weakness,

dizziness, nausea◦ Events leading up

to incident (onset, duration)

◦ Treatment prior to EMS arrival

Objective◦ What you observe◦ Lacerations,

deformities, ecchymosis, paradoxical breathing

◦ Knife sticking out of pt. chest

◦ Treatment prior to EMS arrival

Subjective vs. Objective

Subjective Assessment Begin telling your story Try to be as chronologically correct as

possible How was pt. found, c/o, onset, duration,

severity, associated symptoms, aggravating/alleviating factors

Witness/family statements

Objective Assessment Continue your story with tangible

observations Physical assessment

◦ Head to toe◦ Vectored exam◦ Pertinent (+) and (-) findings◦ DO NOT use words/terms if you don’t know

what they mean!!!! K.I.S.S.◦ Abbreviations

Comments May continue your assessments Treatment (Rx)

◦ No need for redundancy◦ Chronological ◦ Effects of treatment

1st rule of medicine – DO NO HARM◦ Explain your omissions/justifications◦ Transport – pt. position, incidents/change in pt.

status, hospital choice◦ Pt. refusal of treatment/txp – RMA◦ Medical Control



Disposition◦ See list◦ Non-Hospital Disposition Codes◦ Southside Hospital (SSH) - 521◦ Good Samaritan Hospital (GSH) – 515

Crew◦ In charge means technician in charge/team leader of

the patient◦ Person completing the PCR◦ DOES NOT mean highest ranking officer/crew chief on

scene Continuation Form Used - circle

ABBREVIATIONS

Know what you are saying and abbreviating

SPELLING!!

Use approved medical abbreviations

ABBREVIATIONS

LLQ / LLR

ABBREVIATIONS

LLQ – Lower Left Quadrant

LLR – Left Lateral Recumbant

ABBREVIATIONS

DKA / AKA

ABBREVIATIONS

DKA – Diabetic KetoAcidosis

AKA – Also Known As

- Above the Knee Amputation

ABBREVIATIONS

HEENT

ABBREVIATIONS

HEENT – Head, Eyes, Ears, Nose, Throat

HEENT clear??? Document specifically what was

checked◦ Trauma/deformity, pupils, conjunctiva,

discharges, swelling/edema, etc

ABBREVIATIONS

PEARL

PERRL

PERRLA

ABBREVIATIONS

PEARL – Pupils equal and reactive to light

PERRL – Pupils equal round reactive to light

PERRLA – Pupils equal round reactive to light and accommodation

ABBREVIATIONS

PMS

ABBREVIATIONS Pulse, motor, sensory

◦WRONG Premenstrual Syndrome

◦ 46 y/o male found leaning forward in chair c/o abdominal pain. Pt PMS intact

ABBREVIATIONS

WNL

ABBREVIATIONS Within Normal Limits

◦WRONG

We Never Looked◦V/S wnl, trauma exam wnl, PMS wnl

◦Unremarkable is acceptable

ABBREVIATIONS

MALE FEMALE

♂ ♀

GENERAL INFORMATION

The less you write the better.

◦Less likely to make mistakes

◦Less likely to be questioned

GENERAL INFORMATION

100% FALSE!!

◦If you didn’t write it, you didn’t do it

◦Court / subpoena

GENERAL INFORMATION

Be confident in treating your patient and documenting it

Be able to justify any course of action you take or omit

GENERAL INFORMATION

Fill out a PCR for EVERY activation◦ Transport◦ Care transfer◦ Cancellation (even if you don’t roll)◦ Stand-by

GENERAL INFORMATION Remember to tell a story We are an extension of the ER

◦Describe the events leading up to the transfer of care to the ED staff

Be a patient care advocate◦Pt. pedigree information◦Treatment◦Speak up to triage RN / staff

Review ofCompleted PCR’s

Documents

PCR WRITING AND DOCUMENTATION