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Writing a PCR. Nikhil Natarajan, REMT-P Quality Improvement Coordinator Beacon Volunteer Ambulance Corps. Why do we have a Pre-Hospital Care Report.

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writing a pcr

Writing a PCR

Nikhil Natarajan, REMT-P

Quality Improvement Coordinator

Beacon Volunteer Ambulance Corps.

why do we have a pre hospital care report
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
so what is it
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
when to use a pcr
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
parts of a pcr
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
writing a pcr1
SOAP

Subjective

Objective

Assessment

Plan

Writing a PCR
subjective
What the patient told you.

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

Subjective
objective
What you see

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

Objective
assessment
What you found wrong with the patient during your assessment

For example….. Upon PE- CAOx3, PERRL, Lungs clear = bilat., etc., etc.

Assessment
slide10
What you plan on doing for the patient

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

Plan
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.

What to write on a PCR
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.

What not to write on a PCR
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 AMS 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.”

How do I word objectionable phrases into stuff I can use
how do i word objectionable phrases into stuff i can use1
“He was high”

How do you know that the patient was high. Could have had an AMS 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”

How do I word objectionable phrases into stuff I can use
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

Grammar and Spelling
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

Going to court
slide18

CQI

What is it and why do we have it?

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.

Continuous Quality Improvement
some aspects of cqi
Individual PCR Reviews

Drills and Training

Call Audits

A system of checks and balances to ensure that proper care was given for the appropriate diagnosis

Provides for interaction with a Medical Control Physician

Some aspects of CQI
the end
The End
  • Any questions…