When do you have to write a PCR?
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- Posy Charlotte Hood
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1 How to Write a PCR
2 When do you have to write a PCR? Every time you come in contact with a patient Every time you are dispatched for a call and operating as a member of your agency. If you treat a patient at a call but don't transport, you must write a PCR! If you don't find a patient, you must write a PCR! And write in no pt.
3 When NOT to write a PCR Service trips (oil change, gas, etc.) Driver training Parades, shows Educational (i.e., visiting a school)
4 Writing a PCR Most things are self-explanatory patient's name, address, DOB, age, etc. Then there are a few numbers and codes you have to fill in. Date: DUH! (And it s required) Run number: that s up to your agency, but is not required by the DOH Agency code: EMS agency code as assigned by NYS DOH EMSP - required
5 Writing a PCR Location code: required for transporting agencies; not needed by First Response units. Vehicle ID: that s up to you, it s not required Pt Social Security: DOH wants last 4 digits; if you don t get it, fill in with 0 s
6 OK, now the really hard part: the actual writing! ARRRGHHHH!
7 What to write? Anything that you did for the patient Anything you found during the assessment Anything done by another agency: XYZ FD on scene, backboarded & collared pt How you found the patient Anything unusual with the call Where you left the patient Who started care before you got there If you did it, you need to write it
8 What NOT to write Any objectionable language except: If it s a quote from the patient, and pertinent to the patient s condition, write it in quotation marks: Pt says Anything that could be considered libel Example: Pt was drunk Anything you DID NOT do
9 How do I word objectionable comments into stuff I can use? Pt was drunk How do you know? Pt might have head injury, diabetic emergency, stroke, previous injury Possible options: Pt had odor of ETOH on breath Pt s wife says he drank 2 six-packs of beer Pt unable to walk with steady gait.
10 Chief Complaint Should be a direct quote from the patient (or bystander), such as I feel sick or my stomach hurts (it should also be in quotes), even if it has nothing to do with why you are there.
11 Chief Complaint If the patient is unconscious/unresponsive, write that in. If they are in cardiac or respiratory arrest, write that in. If they have no chief complaint, put none stated. If someone else made the call, you can put down their reason for calling ( He started making funny noises, then passed out. )
12 Subjective Assessment: an expansion of the chief complaint How exactly does the patient feel? How were they found (sitting in a chair, lying on the floor, etc.) Were they in care of someone else?
13 Subjective Assessment In an MVA the location of patient (driver, front-seat passenger, etc.), damage to vehicle, steering wheel, pedals, dashboard, seat. Usually starts off: Pt. found (sitting, lying down, in care of, etc.) complaining of (chest pains, nausea, arm pain, etc.)
14 Your findings. Objective Physical Assessment The more you document the better. Does this show you did a full assessment?
15 Objective Physical Assessment One way to start is to run through the initial assessment: Check for responsiveness: Pt. A + O x 3 (patient alert and oriented to person, place and time) (or other mental status)
16 Objective Physical Assessment Check Airway & Breathing: Lung sounds (clear, wheezes, rales, etc.), (bilateral, left side, right side), shortness of breath, etc. Check Circulation: peripheral pulses (good x 4, weak or absent in (specify extremity) Check for Deformity: neuros (good x 4, weak or absent in (specify extremity))
17 Objective Physical Assessment Then put your physical findings, i.e.: a Laceration to (wherever and size), bruising to (wherever). If there are no physical findings then put physical assessment unremarkable"
18 Comments Anything else important? Did the patient's condition change? In an MVA, was the patient walking around, or self-extricate?
19 Comments This is the CYA section. Also used for the continuation of physical assessment. Also anything that someone other than the crew or patent said and start it off whoever states (PD states "blah blah blah")
20 The Mechanism Matters We all know how important assessing the mechanism of injury is. This helps us predict what injuries may have occurred so we respond accordingly. How do you convey that information to someone who can t see what you're seeing?
21 The Mechanism Matters The more descriptive you can be with your reports, the better.
22 The Mechanism Matters Which tells you more about the patient s possible injuries? Pt was passenger in a car that hit a tree. Pt was unbelted front-seat pass in compact car that hit large high speed.
23 Numbers aren t everything Which tells you more? Pt is 25yo % resp 22 Pt is 25yo % c/o rib pain, resp 22 & shallow Pt is 79yo % resp 22 Pt is 79yo % sitting upright, hunched over, resp 22 & labored
24 Examples
25 Chest Pain Chief complaint: "My chest [expletive] hurts like hell" Subjective assessment: pt. c/o substernal crushing chest pain radiating to the lt. arm x3 hours. Pt was working out when pain started. Pain is a 7 on scale of 10. Objective physical assessment: Pt. A+Ox3 lung sounds clear bilat, c/o SOB. Good neuros and perif pulses x4. Pedal edema, minor respiratory distress, accessory muscle use.
26 Chest Pain, cont. Comments: Pt's pain decreased from a 7 to a 5 w/o2. Pt transported w/o incident. Pt's wife states that he drank a six-pack before working out, pt states he drank 2 beers.
27 MVA Chief complaint: "my head hurts" Subjective assessment: Pt. found in driver seat c/o head and neck pain from a high speed MVA head-on collision.
28 MVA, cont Objective physical assessment: Pt verbally responsive, lung sounds absent on rt. side. Bruising to chest, weak neuros both feet, weak pedal pulses. Lac to forehead approx 4 and bruising to RT forearm, Lac to lt. shoulder approx 3 ; rigidity and point tenderness in upper abdominal quadrants. Compound lt. fib-tib fx. c/o SOB w/accessory muscle use. Loss of consciousness unknown time.
29 MVA, cont. Comments: major damage to front end of vehicle, broken windshield by driver side, seat dismounted, steering wheel bent forward, dash dismounted, brake pedal bent. Pt's mental status decreased while enroute to hospital, but still considered verbal.
30 Overdose Chief complaint: "The rats are purple" Subjective assessment: Pt found on floor at a party, verbally responsive, c/o seeing purple rats Objective physical assessment: Pt verbally responsive, lung sounds clear bilat, neuros and perif pulses good x4. Physical assessment unremarkable Comments: bystanders state pt. was unc/unresp for 5 min prior to our arrival, and pt had a bottle of whisky, 6 beers, 5 shots of tequila, and smoked some pot.
31 Minor MVA Chief Complaint: "My neck hurts" Subjective assessment: Pt was found sitting on curb c/o neck pain. Pt was in a minor MVA rear end collision approx 5 mph. No damage to interior of vehicle. Minor damage to rear bumper.
32 Minor MVA, cont Objective physical assessment: pt. A+Ox3 lung sounds clear bilat, neuros and perif pulses good x4. Physical assessment unremarkable, no loss of consciousness Comments: Pt. states they got out of car by themselves. PD and bystanders state that pt. was walking around prior to our arrival. Air bags did not deploy.
33 QI & Investigations Quality Improvement (QI) is a program of systematic evaluation to ensure excellence. Instead of asking "Who caused this to happen?", QI asks "What is wrong with the process that caused this to happen?" It is a judgment linked to mechanisms or a system to effect positive change. That judgment is based on acceptable standards of care provided by written protocols and on-line medical control.
34 QI & Investigations What opens an investigation? Unusual occurrence DOH inquiry or inspection Complaint or report Patient, Family, Hospital staff, other EMS, Law Enforcement
35 QI & Investigations What gets investigated? Individuals (patient harm) Patient complaints Ambulance crashes Diversion of medications Equipment failure Course sponsors, instructors Violations of protocol & Part 800
36 QI & Investigations Enforcement Action Written reprimand Probation Voluntary surrender of card Fines Suspension Revocation Legal stipulations & Hearings
37 In Charge At the bottom of the PCR there is a space for Crew. The first space is labeled IN CHARGE. Who is in charge? Whose name and EMS # get written in this space? This is the space for the person who is treating that patient assessing and determining what needs to be done.
38 And if it ever goes to court, this is the person who will be on the witness stand, explaining what s/he did and why. See the Regional Policy Manual, Policy #15, Coordination of EMS Resources, for more information on who is in charge.
39 Final notes DO NOT EVER write things you did not do. Read, review and KNOW Part and Part Failure to follow these rules can result in losing your certification.
40 Final Notes, cont. Use special care to organize your PCR notes in a chronological narrative. You may want to take notes on another page first. Sometimes you may forget to put things in; add them at the end if you have to, but not if the PCR has already been separated. This document is a suggestion on how to make sure you document what is important in the sections where you have to write all the information.
41 Final notes, cont. Please remember to look over the other sections of the PCR that only require you to fill in boxes or circles. These should be self-explanatory, but if you need any help check the PCR Manual or contact EMSTAR
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