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Review of PCR

PCR Purpose. Medical RecordLegal DocumentProtectionJustificationBillingQITrainingResearch. A Good PCR is ?. AccurateJust the FactsCompleteFill every line inLegibleSloppy Report = Sloppy CareFree of Extraneous informationDon't Label Patients. Tips and tricks to a good PCR. Write the P

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Review of PCR

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    1. Review of PCR / PCR Writing Rick Hines EMT-P, PI

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

    3. A Good PCR is ? Accurate Just the Facts Complete Fill every line in Legible Sloppy Report = Sloppy Care Free of Extraneous information Dont Label Patients

    4. Tips and tricks to a good PCR Write the PCR soon as possible after the call. Dont be afraid to use more than 1 page Extra Careful on SOR Documentation (High probability of law suits)

    5. How do I write a good PCR ? SOAP

    6. Subjective What the Patient told you.

    7. Objective What you see

    8. Assessment What you found wrong with the patient during your assessment

    9. Plan What are you planning on doing for the patient

    10. Remember If you Didnt write it.. You Didnt do it !!!

    11. One for the scrap books.

    12. Tips on writing a GREAT narrative Learn a system early on Dont change styles or systems Think before you write Spell Check TAKE YOUR TIME !!!!! Proof read your narrative !

    13. The C.H.A.R.T. Method C = Chief Complaint or complaining of !

    14. History History of what happened an past medical history

    15. Assessment What you find during your assessment

    16. Responses The responses the patient has to your treatment.

    17. Treatment What treatment you completed for the patient.

    18. The Next Method !! 5 Step Process

    19. C/O or C/C Chief Complaint Note what the patients complaint is

    20. PMHX Past Medical History Includes Meds and Allergies Should be pertinent to the complaint at hand. Examples..(note for Rick)

    21. HXPI History of present Illness or Injury What led up to the call for EMS Length of time for illnesses Brief description of what caused the illness

    22. PE Physical Exam Document your physical Exam Remember to document in a systematic and orderly fashion Head to Toe

    23. TX or RX Treatment of the patient Included is responses to that treatment.

    24. Special Information Long Scene Time ? Obese patient hard to move ? Trapped patient long extrication ? Any other pertinent information ?

    25. In Review the 4 Bes Be thorough Be Confident Be Consistent Be Professional

    26. 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 ?

    27. Video Time Then a Break

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