PCR WRITING AND DOCUMENTATION

1. PCR WRITING AND DOCUMENTATION

2. Objectives of this class • Acceptable / Authorized Medical Abbreviations • GCS • RMA’s / Forms • Rear of PCR • Telling a Story • Requirements • Musts/Omissions • Documentation • Subjective v. Objective • Assessments • Comments • Redundancy

3. WHAT IS A PCR?

5. Pre-hospital Care Report • Pre-hospital– These are issues and conditions the ED staff can’t see and don’t know about. Important to document. • Accidents – condition of car, position of patient • Homes – condition, temperature, medical devices • Nursing facilities – need I say more

6. Pre-hospital Care Report • Care – Simple…What treatment did you provide to the patient • Again, if it’s not visible, the ED staff won’t know what you did • Self treatment prior to EMS arrival

7. Pre-hospital Care Report • Report – As by it’s very definition: • (noun) • a usually detailed account or statement • (transitive verb) • To relate the words or sense of • To make a written record or summary of • To give a formal or official account or statement of

8. Pre-hospital Care Report • Report • Examples • Book reports • Accident reports • Report cards • Reporters

9. Pre-hospital Care Report • Report • TELL A STORY • RELAY INFORMATION

10. 132186 • Can be completed post call COMPONENTS OF THE PCR • 05129 • 32420

11. COMPONENTS OF THE PCR

12. COMPONENTS OF THE PCR • Agency Name – BSBRA • Dispatch Information • Plain English – Chest Pain • EMD Code – 10D3 • Call Location • As specific as possible • Address • “IFO”, “in vicinity of”, intersection, direction, business name, etc. • Location Code – 5154 (Islip Township) • 5100 only if unsure

13. COMPONENTS OF THE PCR

14. COMPONENTS OF THE PCR • Times • Must be filled in prior to leaving the hospital • Call headquarters or MedCom if needed • Must correlate with vital signs

15. COMPONENTS OF THE PCR

16. COMPONENTS OF THE PCR

17. COMPONENTS OF THE PCR • Name – Spell correctly • This is what is used at triage to get pt. into the system • Phone – • should be an emergency contact, NOT the patient’s personal cell • DOB/Age – Again, be accurate • If you can’t do the math and figure out the person’s age, ASK THEM • SSN – Important for patient tracking

18. COMPONENTS OF THE PCR • Jose Diaz • Juan Martinez • Victor Rivera • Julio Gonzalez • Maria Sanchez • Michael Brown • Susan Smith • Tom Robinson • Frank Williams • Karen Jones

19. COMPONENTS OF THE PCR

20. COMPONENTS OF THE PCR • Physician • General Practitioner if possible • Can write in specialists too • Care in Progress on Arrival • Self explanatory • If possible, name and vehicle • Mechanism of Injury Fill in and • Extrication required document • Seat belt used accordingly

21. COMPONENTS OF THE PCR

22. COMPONENTS OF THE PCR • Use the words of the patient • “I fell and hurt my knee” • “I thought I was going to pass out” • Use the words of a witness • “He fell down and hit his head” • “She started shaking a lot” • Do NOT write diagnosis here • “Syncope”, “blunt trauma”, “diabetic” • If patient cannot or doesn’t make a statement: • None – pt unresponsive – pt AMS

23. COMPONENTS OF THE PCR

24. COMPONENTS OF THE PCR • Presenting problem • Fill in circle of ALL that apply • Cardiac related, Respiratory Distress, Pain, Other • Head injury, Fracture, Bleeding • Circle primary condition/incident • Pain and Other – be specific • L sided c/p radiating to jaw and L arm • Nausea, dizziness, AMS

25. COMPONENTS OF THE PCR

26. COMPONENTS OF THE PCR • Fill in circle of all that apply • Other: GERD, Vertigo, Gout, Anxiety, etc • Allergies and Medications • WRITE SMALL • DO NOT write up the side of the PCR • DO NOT use up entire assessment/comment section if the pt. eats the pharmacy daily • Use continuation form • “See list” - unacceptable

27. COMPONENTS OF THE PCR

28. COMPONENTS OF THE PCR • Times MUST correlate with response times!!!!! • Respirations and Pulse • Rate and condition • Blood Pressure • “Palp” or “P” is acceptable – document! • LOC • How does the pt. respond based on stimuli • Alert does not mean oriented

29. COMPONENTS OF THE PCR • 1st set of v/s should be within 1st five minutes of patient contact – if not, document reason for delay • Prolonged extrication, delayed pt. contact, pt. agitation, etc. • Make every effort to obtain 2 sets of v/s, especially if giving treatment – if only one set, document why

30. COMPONENTS OF THE PCR • GCS – Glasgow Coma Scale

31. COMPONENTS OF THE PCR • Eye Opening (1-4) • Similar to LOC , but different

32. COMPONENTS OF THE PCR

33. COMPONENTS OF THE PCR • Verbal Response (1-5) • Oriented • Confused • Inappropriate Words • Incomprehensible Sounds • None

34. COMPONENTS OF THE PCR • Motor Response (1-6) • Obeys Command • Localizes Pain • Withdraw (pain) • Flexion (pain) • Extension (pain) • None

35. COMPONENTS OF THE PCR • Glasgow Coma Scale • For any sum other than 15 or 3, write the individual numbers of each assessment above the total • Eye opening – spontaneous (4) • Verbal Response – confused (4) • Motor Response – obeys command (6) • Total = 14

36. COMPONENTS OF THE PCR • Pupils • Difference between R & L?? • It’s okay if not assessed – document • Skin • Unremarkable means exactly that • CUPS • Critical • Unstable • Potentially Unstable • Stable

37. COMPONENTS OF THE PCR

38. COMPONENTS OF THE PCR • Treatment Given • Fill in circle to all that apply • Fill in all boxes and blank lines • “Other” section– PFA / ES not necessary • Questions regarding specific treatments?

39. COMPONENTS OF THE PCR

40. Subjective vs. Objective • Objective • Object • Something tangible • Can be seen/touched • Measurable fact or evidence • Subjective • Personal perspective • Feelings, beliefs, opinions, attitudes • Existing in the mind • Cannot be seen

41. Subjective vs. Objective • Objective • What you observe • Lacerations, deformities, ecchymosis, paradoxical breathing • Knife sticking out of pt. chest • Treatment prior to EMS arrival • Subjective • What the pt. tells you • Pain, weakness, dizziness, nausea • Events leading up to incident (onset, duration) • Treatment prior to EMS arrival

42. Subjective Assessment • Begin telling your story • Try to be as chronologically correct as possible • How was pt. found, c/o, onset, duration, severity, associated symptoms, aggravating/alleviating factors • Witness/family statements

43. Objective Assessment • Continue your story with tangible observations • Physical assessment • Head to toe • Vectored exam • Pertinent (+) and (-) findings • DO NOT use words/terms if you don’t know what they mean!!!! K.I.S.S. • Abbreviations

44. Comments • May continue your assessments • Treatment (Rx) • No need for redundancy • Chronological • Effects of treatment • 1st rule of medicine – DO NO HARM • Explain your omissions/justifications • Transport – pt. position, incidents/change in pt. status, hospital choice • Pt. refusal of treatment/txp – RMA • Medical Control

45. COMPONENTS OF THE PCR

46. COMPONENTS OF THE PCR • Disposition • See list • Non-Hospital Disposition Codes • Southside Hospital (SSH) - 521 • Good Samaritan Hospital (GSH) – 515 • Crew • In charge means technician in charge/team leader of the patient • Person completing the PCR • DOES NOT mean highest ranking officer/crew chief on scene • Continuation Form Used - circle

47. ABBREVIATIONS • Know what you are saying and abbreviating • SPELLING!! • Use approved medical abbreviations

48. ABBREVIATIONS LLQ / LLR

49. ABBREVIATIONS LLQ – Lower Left Quadrant LLR – Left Lateral Recumbant

50. ABBREVIATIONS DKA / AKA