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Review of PCR / PCR Writing

Review 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

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Review of PCR / PCR Writing

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

  2. PCR Purpose • Medical Record • Legal Document • Protection • Justification • Billing • QI • Training • Research

  3. 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

  4. 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)

  5. 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

  6. What 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.

  7. 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"

  8. PCR Models • SOAP • CHART • Ken’s

  9. How Do I Write a First-Rate PCR ? • SOAP • Subjective • Objective • Assessment • Plan

  10. Subjective • What the Patient told you. • Example ….. • Pt advised she was leaving after eating and slipped in water falling

  11. 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

  12. 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

  13. 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.

  14. Ouch! This will leave a mark!

  15. The C.H.A.R.T. Method • C= Chief Complaint Example Pt c/o pain and swelling to R lower Leg

  16. 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………

  17. 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……….

  18. R= Responses • The responses the patient has to your treatment. Example …… After oxygen the patient skin color start to return to normal…….

  19. T = Treatment • What treatment you administered to the patient. Example …. 02 Cannula at 3 LPM……….

  20. Remember . . . If you Didn’t Write It….. You Didn’t Do It !!!

  21. Ken’s Method 5 Step Process • C/C . . Chief Complaint • HPI . . History of the Present Illness • Exam . . Signs & Symptoms • Rx . . Treatment • Tx . . Transport

  22. C/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.

  23. 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

  24. 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

  25. 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)

  26. 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

  27. Special Information • Long Scene Time ? • Obese patient hard to move ? • Long extrication ? • Any other pertinent information ?

  28. ABC’s of PCRs • Accurate and Honest • Brief but Thorough • Concise but Clear • Consistent • Signature Required

  29. 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 ?

  30. Example of Ken’s 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

  31. 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.

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

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