A basic approach to PCR REPORTS Robby Latta EMS Instructor

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PCR REPORTS
A basic approach to

• Robby Latta
• EMS Instructor / Training Officer
• STILWELL EMS

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Why do we have a Pre-Hospital 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

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Sowhat 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
• its a way for the prehospital care providers to
  prove what treatment he/she gave
• a standardized record

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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

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Parts of a PCR

• A PCR has three copies to it.
• The white copy is retained by the agency
• The yellow copy is used for statewide data
  collection
• The pink copy is retained by the hospital for the
  patients record

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Writing a PCR

• Subjective
• Objective
• Assessment
• Plan

• SOAP

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Subjective

• What the patient told you.

• For example. Patient states that she was walking
  down the street and walked into the light pole.

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Objective

• What you see

• For example. Upon arrival found patient lying on
  ground next to light pole in apparent distress

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Assessment

• What you found wrong with the patient during your
  assessment

• For example.. Upon PE- pt A 0 xs 4,
  PERRL,LSCTA bilaterally.

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Plan

• What you plan on doing for the patient

• For example.. Patient placed on 10 LPM 02 via
  NRBM.

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CHART method

• C Cx or chief complaint (c/c)
• H Hx or History
• A Ax or Assessment
• R Rx or Treatment
• T Tx or Transport

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CHART method

• Cx or chief complaint (c/c) is what the patient
  initially called the ambulance for. Some EMTs
  write the actual pts words in quotes. Such as-
  pt c/o pain in his stomach. Other EMTs
  prefer to write the c/c objectively, such as-
  pt c/c SSCP w/ DOE.
• Example on following slide.

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CHART method

• Cx- c/c is pt thinks hes having a
  heart attack.
• Or
• Cx- c/c is SSCP w/ DOE R/O AMI .

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CHART method

• Hx or History includes the pts Past Medical
  History (PMH) and the History of Present Illness
  (HPI).
• For example you might see..
• Hx- Pt has Hx of COPD, CHF, and ESRD. Pt has
  NKDA. Pt has had CP xs 3 hours, not relieved by
  rest or NTG. Pt has NTG Rx prn for CP and stated
  he took one about an hour ago PTAA, with no
  relief.

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CHART method

• Ax or Assessment include all findings when you
  assess the pt your LOC, V/S, and any physical
  findings in you assessment should be documented
  here.
• For Example see following slide..

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CHART method

• Ax- UAA found pt AO xs 4, sitting on couch, c/o
  dull CP of 8 on 1/10 scale, radiating to left
  arm and lower jaw. Obtain baseline v/s P-112 and
  regular, R-20 and labored, B/P 160/98, SpO2
  92_at_RA. Lung sounds have rales bilaterally,
  Pupils PEARL, PMS v good xs 4, Skin is cool
  clammy and pale. Note 2 pitting edema in lower
  ext, everything else unremarkable.

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CHART method

• Rx or Treatment can be confusing, because in all
  other medical documentation Rx means
  prescription and Tx means treatment. However
  for the CHART method Rx means treatment. In
  this subheading you may list all interventions
  done by you on behalf of the patient.
• For example see following slide

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CHART method

• Rx- Place pt on cot in POC, place pt on O2 _at_ 12
  lpm NRB, Admin ASA 81 mg xs 2, Assist pt with
  his NTG (second dose _at_ 1554) .04 mg SL, est IV in
  L hand with 18 ga cath with NS 10 gtt set, _at_
  250 ml hr. Perform Blood Draw, and a obtain a
  Chemstrip 215.

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CHART method

• Tx or Transport is all things to do with pt
  transport including destination, transport
  status, and any incidents that happen while
  enroute to the medical facility. This includes
  your ongoing assessment and treatment evaluation.
  
• For example see following slide.

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CHART method

• Tx- Transport non-emg to SMH. Enroute monitor v/s
  q5m note B/P? to 130/88, CP? to 5 on 1/10 scale,
  P? to 100, and SpO2 ?99_at_12Lpm NRB. Trending v/s
  listed below. Continue to monitor v/s while
  enroute noting no other ?s. TOT ER staff upon
  arrival.

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CHART method

• Put all those together and you get something like
  this

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CHART method

• This method is by no means the only, or even the
  best way, to write a PCR narrative. However, it
  is a simple way, and is easily understood. The
  BEST way to write your narrative, is whatever
  works best for you..

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PCR Narratives

• Most EMTs develop their own style for writing
  run sheets, and stick to it. As long as it works
  for you and you document well, it makes no
  difference how you write it.
• Remember your narrative should paint a picture
  of the entire call from start to finish. Anyone
  who reads it should have no trouble as to
  deciphering what exactly happened.

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If you didnt write it..
and Remember

• You didnt do it!

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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.

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What not to write on a PCR

• Any foul or objectionable language
• Anything that could be considered libel
• for example He was drunk

• Dont write on anything that you have lying on
  top of a PCR because it will copy onto the PCR
  because of the carbon paper.

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How do I word objectionable phrases into stuff I
can use

• He was drunk
• How do you know that the patient was drunk. Could
  have had an Altered LOC due to a head injury, a
  diabetic emergency, a stroke, etc.

• Patient had an odor of intoxicating substance on
  breath
• Patient admits to drinking 2 40 ounce bottles of
  beer.

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How do I word objectionable phrases into stuff I
can use

• He was high
• How do you know that the patient was high. Could
  have had an Altered LOC due to a head injury, a
  diabetic emergency, a stroke, etc.

• Patient admits to using illicit substances
• Patient unable to stand on his own without
  staggering and has auditory and visual
  hallucinations

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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 youre 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

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Going to court

• Better be sure that your documentation was
  well-written
• Most EMS personnel dont go to court until 4-5
  years after the call was done.

• Dont

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CQI

• What is it and why do we have it?

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Continuous Quality Improvement

• We have it because we have it. According to NYS
  DOH Policy 96-01.

• It makes us better EMTs and Paramedics
• We learn things that we could do differently and
  more importantly things that we shouldnt do.

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Some aspects of CQI

• Individual PCR Reviews
• Drills and Training
• Call Audits
• CEU classes
• Etc,

• A system of continuous review and checks and
  balances to ensure that proper care was given for
  the appropriate diagnosis.
• Provides for interaction with a Medical Control
  Physician and other health care affiliates.

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The End

• Any questions