Writing a Writing a PCRPCR

Nikhil Natarajan, REMT-PNikhil Natarajan, REMT-P

Quality Improvement CoordinatorQuality Improvement Coordinator

Beacon Volunteer Ambulance Corps.Beacon Volunteer Ambulance Corps.

Why do we have Why do we have a Pre-Hospital a Pre-Hospital Care ReportCare Report

It was developed by a It was developed by a committee of EMS committee of EMS providers and providers and administrators assembled administrators assembled from across the state for from across the state for the purpose of the purpose of establishing a statewide establishing a statewide EMS data systemEMS data system

So…what is it?So…what is it?

The PCR is:The PCR is: a medical recorda medical record

– the form becomes part of the form becomes part of the patient record and the patient record and allows for continuity of careallows for continuity of care

a legal documenta legal document it’s a way for the prehospital it’s a way for the prehospital

care providers to prove what care providers to prove what treatment he/she gavetreatment he/she gave

a standardized recorda standardized record

When to use a When to use a PCRPCR

A PCR should be filled out A PCR should be filled out for for everyevery call, including call, including emergencies, fire emergencies, fire standbys, mutual aid standbys, mutual aid standbys, etc.standbys, etc.

If you were dispatched for If you were dispatched for a call a PCR needs to be a call a PCR needs to be filled out even if you were filled out even if you were cancelledcancelled

Parts of a PCRParts of a PCR

A PCR has three copies to it.A PCR has three copies to it.

The white copy is retained The white copy is retained by the agencyby the agency

The yellow copy is used The yellow copy is used for statewide data for statewide data collectioncollection

The pink copy is retained The pink copy is retained by the hospital for the by the hospital for the patient’s recordpatient’s record

Writing a PCRWriting a PCR

SOAPSOAP SubjectiveSubjective ObjectiveObjective AssessmentAssessment PlanPlan

SubjectiveSubjective

What the What the patient told patient told you.you.

For For example…. example…. PPatient atient states that states that she was she was walking walking down the down the street and street and walked into walked into the light the light pole.pole.

ObjectiveObjective

What you What you seesee

For For example…. example…. Upon arrival Upon arrival found found patient lying patient lying on ground on ground next to light next to light pole in pole in apparent apparent distressdistress

AssessmentAssessment

What you What you found wrong found wrong with the with the patient patient during your during your assessmentassessment

For For example….. example….. Upon PE- Upon PE- CAOx3, CAOx3, PERRL, PERRL, Lungs clear Lungs clear = bilat., etc., = bilat., etc., etc.etc.

PlanPlan

What you What you plan on plan on doing for the doing for the patientpatient

For For example….. example….. Patient Patient placed on 10 placed on 10 LPM 02 via LPM 02 via NRBM.NRBM.

If you didn’t If you didn’t write it…..write it…..

You You didn’t do didn’t do

it!it!

What to write on What to write on a PCRa PCR

Anything that Anything that you did for you did for the patientthe patient

Anything you Anything you found during found during the the assessmentassessment

How you How you found the found the patientpatient

Where you Where you left the left the patientpatient

Anything Anything unusual with unusual with the callthe call

Who started Who started care before care before you got you got therethere

If you did it, If you did it, you should you should write it.write it.

What not to write What not to write on a PCRon a PCR

Any foul or Any foul or objectionablobjectionable languagee language

Anything Anything that could that could be be considered considered libellibel– for for

example: example: “He was “He was drunk”drunk”

Don’t write Don’t write on anything on anything that you that you have lying have lying on top of a on top of a PCR because PCR because it will copy it will copy onto the PCR onto the PCR because of because of the carbon the carbon paper.paper.

How do I word How do I word objectionable objectionable

phrases into stuff phrases into stuff I can useI can use ““He was He was

drunk”drunk”

How do you How do you know that know that the patient the patient was drunk. was drunk. Could have Could have had an AMS had an AMS due to a due to a head injury, head injury, a diabetic a diabetic emergency, emergency, a stroke, etc.a stroke, etc.

““Patient had Patient had an odor of an odor of intoxicating intoxicating substance substance on breath”on breath”

““Patient Patient admits to admits to drinking 2 drinking 2 40 ounce 40 ounce bottles of bottles of beer.”beer.”

How do I word How do I word objectionable objectionable

phrases into stuff phrases into stuff I can useI can use ““He was He was

high”high”

How do you How do you know that know that the patient the patient was high. was high. Could have Could have had an AMS had an AMS due to a due to a head injury, head injury, a diabetic a diabetic emergency, emergency, a stroke, etc.a stroke, etc.

““Patient Patient admits to admits to using illicit using illicit substances”substances”

““Patient Patient unable to unable to stand on his stand on his own without own without staggering and staggering and has auditory has auditory and visual and visual hallucinations”hallucinations”

Grammar and Grammar and SpellingSpelling

Make sure Make sure that your that your grammar grammar and spelling and spelling are correct. are correct. It will make It will make a big a big difference to difference to people people reading it, reading it, including including lawyers!!lawyers!!

If you’re not If you’re not careful with careful with your spelling, your spelling, how careful how careful were you with were you with your patient your patient care.care.

Your PCR is full Your PCR is full of fun-filled of fun-filled words. words. Remember, Remember, most of what most of what you need to you need to write is write is already on already on your PCRyour PCR

Going to courtGoing to court

Better be Better be sure that sure that your your documentatidocumentation was well-on was well-writtenwritten– Most EMS Most EMS

personnel personnel don’t go to don’t go to court until court until 4-5 years 4-5 years after the after the call was call was done.done.

Don’tDon’t

CQICQI

What is it and why do What is it and why do we have it?we have it?

Continuous Continuous Quality Quality

ImprovementImprovement We have it We have it

because we because we have it. have it. According to According to NYS DOH NYS DOH Policy 96-01.Policy 96-01.

It makes us It makes us better EMT’s better EMT’s and and ParamedicsParamedics

We learn We learn things that things that we could do we could do differently differently and more and more importantly importantly things that things that we shouldn’t we shouldn’t do.do.

Some aspects of Some aspects of CQICQI

Individual Individual PCR ReviewsPCR Reviews

Drills and Drills and TrainingTraining

Call AuditsCall Audits

A system of A system of checks and checks and balances to balances to ensure that ensure that proper care proper care was given for was given for the the appropriate appropriate diagnosisdiagnosis

Provides for Provides for interaction interaction with a Medical with a Medical Control Control PhysicianPhysician

The EndThe End

Any questions…Any questions…