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Transcript of Requirements Musts/Omissions Documentation Subjective v. Objective Assessments Comments ...
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PCR WRITING AND DOCUMENTATION
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Requirements Musts/Omissions Documentation Subjective v.
Objective Assessments Comments Redundancy
Acceptable / Authorized Medical Abbreviations
GCS RMA’s / Forms Rear of PCR Telling a Story
Objectives of this class
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WHAT IS A PCR?
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◦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
Pre-hospital Care Report
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◦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
Pre-hospital Care Report
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◦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
Pre-hospital Care Report
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◦Report Examples
Book reports Accident reports Report cards Reporters
Pre-hospital Care Report
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◦Report
◦ TELL A STORY
◦ RELAY INFORMATION
Pre-hospital Care Report
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COMPONENTS OF THE PCR
Date (mm/dd/yr)
07/18/13
132186
Can be completed post call
05129 32420
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COMPONENTS OF THE PCR
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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
COMPONENTS OF THE PCR
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COMPONENTS OF THE PCR
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Times
◦ Must be filled in prior to leaving the hospital
◦ Call headquarters or MedCom if needed◦ Must correlate with vital signs
COMPONENTS OF THE PCR
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COMPONENTS OF THE PCR
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COMPONENTS OF THE PCR
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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
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COMPONENTS OF THE PCR
- Jose Diaz- Juan Martinez- Victor Rivera- Julio Gonzalez- Maria Sanchez
Michael Brown Susan Smith Tom Robinson Frank Williams Karen Jones
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COMPONENTS OF THE PCR
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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
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COMPONENTS OF THE PCR
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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
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COMPONENTS OF THE PCR
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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
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COMPONENTS OF THE PCR
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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
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COMPONENTS OF THE PCR
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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
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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
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COMPONENTS OF THE PCR
◦ GCS – Glasgow Coma Scale
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COMPONENTS OF THE PCR
◦Eye Opening (1-4)
Similar to LOC , but different
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COMPONENTS OF THE PCR
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COMPONENTS OF THE PCR
◦Verbal Response (1-5) Oriented Confused Inappropriate Words Incomprehensible Sounds None
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COMPONENTS OF THE PCR
◦Motor Response (1-6) Obeys Command Localizes Pain Withdraw (pain) Flexion (pain) Extension (pain) None
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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
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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
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COMPONENTS OF THE PCR
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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?
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COMPONENTS OF THE PCR
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Subjective◦Personal
perspective◦Feelings, beliefs,
opinions, attitudes
◦Existing in the mind
◦Cannot be seen
Objective◦Object◦Something
tangible◦Can be
seen/touched◦Measurable fact
or evidence
Subjective vs. Objective
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Subjective◦What the pt. tells
you◦Pain, weakness,
dizziness, nausea◦Events leading up
to incident (onset, duration)
◦Treatment prior to EMS arrival
Objective◦What you observe◦Lacerations,
deformities, ecchymosis, paradoxical breathing
◦Knife sticking out of pt. chest
◦Treatment prior to EMS arrival
Subjective vs. Objective
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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
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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
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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
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COMPONENTS OF THE PCR
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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
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ABBREVIATIONS
Know what you are saying and abbreviating
SPELLING!!
Use approved medical abbreviations
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ABBREVIATIONS
LLQ / LLR
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ABBREVIATIONS
LLQ – Lower Left Quadrant
LLR – Left Lateral Recumbant
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ABBREVIATIONS
DKA / AKA
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ABBREVIATIONS
DKA – Diabetic KetoAcidosis
AKA – Also Known As
- Above the Knee Amputation
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ABBREVIATIONS
HEENT
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ABBREVIATIONS
HEENT – Head, Eyes, Ears, Nose, Throat
HEENT clear??? Document specifically what was
checked◦ Trauma/deformity, pupils, conjunctiva,
discharges, swelling/edema, etc
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ABBREVIATIONS
PEARL
PERRL
PERRLA
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ABBREVIATIONS
PEARL – Pupils equal and reactive to light
PERRL – Pupils equal round reactive to light
PERRLA – Pupils equal round reactive to light and accommodation
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ABBREVIATIONS
PMS
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ABBREVIATIONS Pulse, motor, sensory
◦WRONG
Premenstrual Syndrome◦ 46 y/o male found leaning forward in chair
c/o abdominal pain. Pt PMS intact
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ABBREVIATIONS
WNL
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ABBREVIATIONS Within Normal Limits
◦WRONG
We Never Looked
◦V/S wnl, trauma exam wnl, PMS wnl
◦Unremarkable is acceptable
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ABBREVIATIONS
MALE FEMALE
♂ ♀
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GENERAL INFORMATION
The less you write the better.
◦Less likely to make mistakes
◦Less likely to be questioned
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GENERAL INFORMATION
100% FALSE!!
◦If you didn’t write it, you didn’t do it
◦Court / subpoena
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GENERAL INFORMATION
Be confident in treating your patient and documenting it
Be able to justify any course of action you take or omit
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GENERAL INFORMATION
Fill out a PCR for EVERY activation◦ Transport◦ Care transfer◦ Cancellation (even if you don’t roll)◦ Stand-by
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GENERAL INFORMATION Remember to tell a story We are an extension of the ER
◦Describe the events leading up to the transfer of care to the ED staff
Be a patient care advocate◦Pt. pedigree information◦Treatment◦Speak up to triage RN / staff
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Review ofCompleted PCR’s