Writing a PCR

1. Writing a PCR Nikhil Natarajan, REMT-P Quality Improvement Coordinator Beacon Volunteer Ambulance Corps.

2. 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

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. 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. 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. SOAP Subjective Objective Assessment Plan Writing a PCR

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

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

9. What you found wrong with the patient during your assessment For example….. Upon PE- CAOx3, PERRL, Lungs clear = bilat., etc., etc. Assessment

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

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

12. 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

13. 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

14. “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

15. “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

16. 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

17. 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

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

19. 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

20. 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

21. The End • Any questions…