review of pcr / pcr writing ken l. hendricks, ed.s, pi, nremtp and rick hines emt-p, pi february...
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Review of PCR / PCR WritingReview of PCR / PCR WritingReview of PCR / PCR WritingReview 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
• 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
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)
• 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 NarrativeWriting 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
• 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 WriteWhat 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.
• 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 ISuggestions 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"
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 ModelsPCR Models
• SOAPSOAP
• CHARTCHART
• Ken’sKen’s
• SOAPSOAP
• CHARTCHART
• Ken’sKen’s
How Do I Write a First-Rate PCR ?
• SOAP• SOAP
• Subjective
•Objective
•Assessment
•Plan
Subjective
• What the Patient told you.
• What the Patient told you.
• Example …..
Pt advised she was leaving after eating and slipped in water falling
Objective
• What You See
• 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
Assessment
• What was found
wrong with the patient
during 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
• 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!Ouch! This will leave a mark!
The C.H.A.R.T. Method
• CC = Chief Complaint
• CC = Chief Complaint
Example
Pt c/o pain and swelling to R lower Leg
H = History
• History of what
happened and past medical
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
• 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.
• 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.
• What treatment
you administered
to the patient.
Example ….
02 Cannula at 3 LPM……….
Remember . . .Remember . . .
If you Didn’t Write It…..If you Didn’t Write It…..You Didn’t Do It !!!You Didn’t Do It !!!
If you Didn’t Write It…..If you Didn’t Write It…..You Didn’t Do It !!!You Didn’t Do It !!!
Ken’s MethodKen’s Method
5 Step Process5 Step Process
• C/C . . Chief Complaint
• HPI . . History of the Present Illness
• Exam . . Signs & Symptoms
• Rx . . Treatment
• Tx . . Transport
C/C . . Chief ComplaintC/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.
• 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 IllnessHPI . . 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
• 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 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
• 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 . . TreatmentRx . . 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)
• 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 . . TransportTx . . 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
• 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
• Long Scene Time ?• Obese patient hard to move ?• Long extrication ?• Any other pertinent information ?
• Long Scene Time ?• Obese patient hard to move ?• Long extrication ?• Any other pertinent information ?
ABC’s of PCRsABC’s of PCRs
• Accurate and Honest• Brief but Thorough • Concise but Clear• Consistent• Signature Required
• 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 ?
• 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 . . CVAExample of Ken’s Method . . CVA
C/C: Slurred SpeechHPI: 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 teethLegs: R drifts to R; Arms; R drifts to R; limited strength R, unable to touch R fingers to thumbGrips; weak to R, Speech; slurredCMSx4 present, Negative for DCAP-BTLS, Bilateral/= Chest Expansion, Negative JVD, Negative
for Respiratory S et S, unable to stand without assistanceRx: Pt. assessment completed, 4L 02/NC, SL c 18CON by KH to L wrist, protected R side of
pt with pillows/blankets on cotTx: 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 IISuggestions 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.
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 IISuggestions II
If you get this far, make up one of If you get this far, make up one of your own submit it to me your own submit it to me
and get some extra credit.and get some extra credit. thanks
If you get this far, make up one of If you get this far, make up one of your own submit it to me your own submit it to me
and get some extra credit.and get some extra credit. thanks