Review of PCR PCR Writing

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Review of PCR / PCR Writing
Ken L. Hendricks, Ed.S, PI, NREMTP and Rick Hines
EMT-P, PI February 2009

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PCR Purpose

• Medical Record
• Legal Document
• Protection
• Justification
• Billing
• QI
• Training
• Research

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A Good PCR Requires . . .

• Accuracy
• Just the Facts
• Completeness
• Fill every line in
• Legibility
• Sloppy Report Sloppy Care
• Free of Extraneous Information
• Dont Label Patients

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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)

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Writing an Effective Narrative

• Learn a System
• Be Consistent
• Think Before you Write
• Spell Check
• Take your Time
• Re-Read Proof Read the Narrative
• Use Accepted Abbreviations/Terms

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What Not to Write

• Any foul or objectionable language.
• Anything that could be considered libel for ex.
  He was drunk
• Dont write on anything that you have lying on
  top of a PCR. It will be copied to the PCR.

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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"

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PCR Models

• SOAP
• CHART
• Kens

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How Do I Write a First-Rate PCR ?

• SOAP

• Subjective
• Objective
• Assessment
• Plan

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Subjective

• What the Patient told you.

• Example ..
• Pt advised she was leaving after eating and
  slipped in water falling

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Objective

• What You See

• Example .
• 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

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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

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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.

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Ouch! This will leave a mark!
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The C.H.A.R.T. Method

• C Chief Complaint

Example Pt c/o pain and swelling to R lower Leg
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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
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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.
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R Responses

• The responses the patient has to your treatment.

Example After oxygen the patient skin color
start to return to normal.
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T Treatment

• What treatment you administered to the patient.

Example . 02 Cannula at 3 LPM.
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Remember . . .

• If you Didnt Write It..
• You Didnt Do It !!!

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Kens Method

• 5 Step Process

• C/C . . Chief Complaint
• HPI . . History of the Present Illness
• Exam . . Signs Symptoms
• Rx . . Treatment
• Tx . . Transport

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C/C . . Chief Complaint

• Chief Complaint
• What the patients 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.

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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

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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

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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)

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Tx . . Transport

• 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

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Special Information

• Long Scene Time ?
• Obese patient hard to move ?
• Long extrication ?
• Any other pertinent information ?

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ABCs of PCRs

• Accurate and Honest
• Brief but Thorough
• Concise but Clear
• Consistent
• Signature Required

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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 ?

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Example of Kens 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
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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.

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Suggestions II

• If you get this far, make up one of your own
  submit it to me
• and get some extra credit.
• thanks