Review 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

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 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

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.

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"

PCR ModelsPCR Models

• SOAPSOAP

• CHARTCHART

• Ken’sKen’s

How Do I Write a First-Rate PCR ?

• SOAP• Subjective

•Objective

•Assessment

•Plan

Subjective

• What the Patient told you.

• Example …..

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

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

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!Ouch! This will leave a mark!

The C.H.A.R.T. Method

• CC = 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 . . .Remember . . .

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 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.

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

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

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)

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

Special 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

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 . . CVAC/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.

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