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

Why do we have a Pre-Hospital Care Report l 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

So…what is it? The PCR is: l a medical record –the form becomes part of the patient record and allows for continuity of care l a legal document l it’s a way for the prehospital care providers to prove what treatment he/she gave l a standardized record

When to use a PCR l A PCR should be filled out for every call, including emergencies, fire standbys, mutual aid standbys, etc. l If you were dispatched for a call a PCR needs to be filled out even if you were cancelled

Parts of a PCR A PCR has three copies to it. l The white copy is retained by the agency l The yellow copy is used for statewide data collection l The pink copy is retained by the hospital for the patient’s record

Writing a PCR l SOAP l Subjective l Objective l Assessment l Plan

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

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

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

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

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

What to write on a PCR l Anything that you did for the patient l Anything you found during the assessment l How you found the patient l Where you left the patient l Anything unusual with the call l Who started care before you got there l If you did it, you should write it.

What not to write on a PCR l Any foul or objectionable language l Anything that could be considered libel –for example: “He was drunk” l 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.

How do I word objectionable phrases into stuff I can use l “He was drunk” l 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. l “Patient had an odor of intoxicating substance on breath” l “Patient admits to drinking 2 40 ounce bottles of beer.”

How do I word objectionable phrases into stuff I can use l “He was high” l 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. l “Patient admits to using illicit substances” l “Patient unable to stand on his own without staggering and has auditory and visual hallucinations”

Grammar and Spelling l Make sure that your grammar and spelling are correct. It will make a big difference to people reading it, including lawyers!! l If you’re not careful with your spelling, how careful were you with your patient care. l Your PCR is full of fun-filled words. Remember, most of what you need to write is already on your PCR

Going to court l Better be sure that your documentatio n was well- written –Most EMS personnel don’t go to court until 4-5 years after the call was done. l Don’t

CQI What is it and why do we have it?

Continuous Quality Improvement l We have it because we have it. According to NYS DOH Policy l It makes us better EMT’s and Paramedics l We learn things that we could do differently and more importantly things that we shouldn’t do.

Some aspects of CQI l Individual PCR Reviews l Drills and Training l Call Audits l A system of checks and balances to ensure that proper care was given for the appropriate diagnosis l Provides for interaction with a Medical Control Physician

The End l Any questions…