1. Documentation

2. Patient Care Record (PCR)
A legal document that serves as a record of all aspects of care that your patient received from the time of dispatch to the arrival at the hospital.

3. PCR
Accuracy is paramount because this document serves the following six functions
Continuity of care
Legal documentation
Education
Administrative information
Research record
Evaluation of quality improvement

4. Information collected
Patient care info
Chief complaint
LOC/AVPU/mental status
Vital signs
Initial assessment
Age, Gender
Care rendered
Response to Tx
Observations at scene
Final patient disposition
Administrative info
Time of incident
Time of dispatch
Time of arrrival at patient
Time left scene
Time arrived at hospital
Time care was transferred
Name of who transferred care to
Patient Demographics

5. PCR Some PCR’s are hand written documents Clear penmanship
Neat appearance
Concise information.
Spelling and grammar

6. PCR Some states have adopted electronic PCR’s
WV is one of those states
Series of check boxes with narrative
Won’t allow incomplete documentation because of mandatory fields that must be filled in.
Either a print out of PCR or a drop sheet must be left at hospital for continuity of care.

7. Narrative Arguably the most important section of the PCR
Paints a picture of the incident
Observations of scene
Initial patient disposition
Assessment findings
Treatments rendered
Reassessment after Tx
Final patient disposition
Think while writing a narrative: If I read this document 5 years from now will I be able to understand what happened !

8. Refusals
Use the narrative to describe circumstances surrounding incident
Describe incident
Document any complaints and assessment done
Document refusal
Document patient capacity
Document explanation of risks and benefits of care vs refusal
Document patient understanding
Explain that they can call back or seek treatment somewhere else if needed.
Describe any precautions taken
Made sure a family member was with patient
Advised patient to contact physician
Collect signatures of patient and witness other than crew members
***** DON’T JUST WRITE PATIENT REFUSED AID ****

9. Use non judgmental description of events
Appropriate
There was an odor of alcohol around patient
Patient reported drinking alcohol today
Child had multiple bruises in various stages of healing
Non Appropriate
Patient was drunk
Child had signs of abuse by parents

10. Tips
Don’t use jargon that is only understood by members of your agency
Only use approved abbreviations
Spelling counts
Remember these documents may be read by individuals that are not health care professionals
Billing agents
Attorneys
Patient or family of patient
Data entry personnel for research purposes

11. EMSPIC.com User name student1 Password student1
Review Premise PCR
EMSPIC.com
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Password student1