PCR REPORTS PowerPoint PPT Presentation

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1. 1 PCR REPORTS Robby Latta EMS Instructor / Training Officer STILWELL EMS

2. 2

3. 3 So…what 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 it’s a way for the prehospital care providers to prove what treatment he/she gave a standardized record

4. 4 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

5. 5 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 patient’s record

6. 6 Writing a PCR SOAP Subjective Objective Assessment Plan

7. 7 Subjective What the patient told you. For example…. Patient states that she was walking down the street and walked into the light pole.

8. 8 Objective What you see For example…. Upon arrival found patient lying on ground next to light pole in apparent distress

9. 9 Assessment What you found wrong with the patient during your assessment For example….. Upon PE- pt A & 0 x’s 4, PERRL,LSCTA bilaterally.

10. 10 Plan What you plan on doing for the patient For example….. Patient placed on 10 LPM 02 via NRBM.

11. 11 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

12. 12 CHART method Cx or chief complaint (c/c) is what the patient initially called the ambulance for. Some EMTs write the actual pt’s 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….

13. 13 CHART method Cx- c/c is pt ‘thinks’ he’s “having a heart attack”. Or Cx- c/c is SSCP w/ DOE; R/O AMI .

14. 14 CHART method Hx or History includes the pt’s 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 x’s 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.

15. 15 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…..

16. 16 CHART method Ax- UAA found pt A&O x’s 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= [email protected] Lung sounds have rales bilaterally, Pupils PEARL, PMS v good x’s 4, Skin is cool clammy and pale. Note +2 pitting edema in lower ext, everything else unremarkable.

17. 17 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……

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

19. 19 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…….

20. 20 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 [email protected] NRB. Trending v/s listed below. Continue to monitor v/s while enroute noting no other ?’s. TOT ER staff upon arrival.

21. 21 CHART method Put all those together and you get something like this……

22. 22 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..

23. 23 PCR Narratives Most EMT’s 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.

24. 24 If you didn’t write it….. You didn’t do it!

25. 25 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.

26. 26 What not to write on a PCR Any foul or objectionable language Anything that could be considered libel for example: “He was drunk” Don’t write on anything that you have lying on top of a PCR because it will copy onto the PCR because of the carbon paper.

27. 27 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.”

28. 28 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”

29. 29 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 you’re 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

30. 30 Going to court Better be sure that your documentation was well-written Most EMS personnel don’t go to court until 4-5 years after the call was done. Don’t

31. 31 CQI What is it and why do we have it?

32. 32 Continuous Quality Improvement We have it because we have it. According to NYS DOH Policy 96-01. It makes us better EMT’s and Paramedics We learn things that we could do differently and more importantly things that we shouldn’t do.

33. 33 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.

34. 34 The End Any questions…

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