Learning how to do a good PCR.

[EMTDenny]

Alright, my EMT class did not emphasize on the PCR subject so much as I think they should have. Now i went on google to look for a good (How to do a good PCR) But I really did not find anything. Now, I know a little to a PCR but not as much as I should know. Does anyone have a good link to a website about PCR and explaining it. Thank you.

[Kiwiology]

- Immediate history

- Past medical history

- Exam findings with pertinant negatives

- Treatment and response to treatment

For example

C/O chest pain 8/24 began at rest, constant sharp, substernal pain radiates to back and right arm 7/10

PMH MI x 2 1999, 2004, subseq CABG x 2, HTN, NIDDM, hyperlipidaemia, mitral valve stenosis

NKA, meds ASA, inhibace, metaprolol, GTN, lipitor, coumadin, metformin

O/E airway normal, resp fast, shallow, circ adequate distal pulses good, diaphoretic ++, BP 180/100, PR 80 reg, RR 30, SPO2 98% RA, temp 37°, bs fine crackles lower lobes, no SOB, audible diasystolic murmur, pain not worse on inspiration, no JVD, no preripheral edema, no pitting, chest wall not tender/no MSK pain, no productive cough, no rash, no palp abdo masses

ECG sinus tachycardia with 2-3mm ST elevation in anterior leads

O2/ASA, GTN ineffective, pain relieved with IV morphine, serial 12 leads, blood for TnT, U+E, hospital

Below this is where we would list times, dosages of drugs and fluids

Another way is to list differential diagnosis and pertinant negatives e.g. for this bloke might be ...

DDx plueritic - no pain on deep insp, DDx AAA - no palp masses, good pedal pulses, no tearing sensation, DDx MSK - no recent MSK trauma, chest wall not tender

... or if you are unsure between say asthma or cardiac wheeze you could write something like this

"? cardiac wheeze/ pt no hx asthma, no SOB, audbl wheezes all lobes, hx HTN/hyperlipidaemia, no JVD, no perhiperal edema, well perfused, no added heart sounds, neg ECG changes, salbutamol ineffective"

Edited October 1, 2011 by kiwimedic

[DwayneEMTP]

Some advice I took from Dustdevil (You don't know him yet) that was golden..

Do you personally know any cops? That is where you should go for report writing skills before you even begin to practice PCRs, if you can. I hired one for a couple of hours as a tutor and man, it changed everything for me about report writing.

Not trying to be a smartass.That truly is a great way to go.

Dwayne

[DFIB]

I have learned valuable lessons in PCR from an istructor who is a paramedic and an EMS lawyer. His main point to me is to use as many of the patients words as you can instead of simply stating fact.

It is difficult to do and I have not mastered it yet.

[Bieber]

Dwayne, share a glimmer of what you learned with us. I'll post a sample PCR of mine tomorrow--time for me to go to bed.

-Bieber

[Kiwiology]

Documenting what the patient describes is not a bad idea, but you have to be subjecive

Some bloke who reckons "I got pissed and fell down so nunggered my leg" is best turned into "today ETOH ++, fall > # tib/fib"

However, documenting "c/o abdo pain 2/7 - descrbd as sharp, incr w/ movement, onset left illiac fossac, slowly migrated inferior and towards RLQ over last 24h" is fine

I have read some absolutely bloody horrible PRFs in my time, absolutely shocking, various Egyptian looking symbols and two letter words and poor handwriting, full of irrelevant shit .... make it sharp and clinically relevant

[DwayneEMTP]

Man...I'm not sure exactly how to describe it exactly, just clear and concise. Though I use very few abbreviations as I don't find that it saves me a lot of time doing computer PCRs. I'm not pretending to be good at PCRs, only to be happy with the information they contain and the order it's contained in, but I'll play and paste one below..

Hell...looking through this I really, really want to change it some, but that seems like a bullshit move for some reason...so here it is, as submitted.

Called by neighbor to the the residence of a 46 y/o female. Neighbor states that patient is having difficulty breathing x three days. Neighbor warns that pt is combative and uncooperative. (Note:smell of alcohol and behavior of neighbor causes medic to regard her comments with suspicion) Pt states that she has had a 'little cough' for the past three or four days. Pt denies sob, productive cough, rhinorrhea, tinitus, h/a, throat pain, c/p, dizziness. Pt states to feeling well other than noted cough that she says "probably comes from my smoking." Pt states that she is home bound secondary to "being retarded." Pt denies PPHx other than noted, -Meds. Pt refuses transport to the ER.

U/A pt is found to be supine in her bed. Her room is comfortably warm and appears well kept and sanitary, her clothes and person appear recently cleaned. Pt's affect is mild, of good humor, cooperative, but that of a much younger person, perhaps a pre-teen. Pt is AAOx4, appropriately aware of sounds and actions occurring around her, speech is clear/concise/appropriate, PERRL, HEENT unremarkable, neck pliant without pain to palp/ROM, L/S full/equal bilat with very light localized wheezes in R lower lobe, no significant change in sounds with prompted cough, cough unproductive, SPO2 97% r/a, 100% 2L O2, P 84/full/reg, B/P 128/76, skins p/w/d/afebrile to touch, pt appears atraumatic globally to clothed inspection. No s/s of emergent pathology reported or discovered during physical exam.

Wheezing without sob, likely chronic.

O2 2L n/c placed by Fire prior to medic arrival, vitals, SPO2, historical exam, physical exam. O2 removed, SPO2 falls to 97% and remains there throughout remainder of pt contact. Pt continues to refuse transport. Though pts mentation is well below that expected of a normally developing adult PD states that pt retains her right to refuse, living autonomously with periodic checks from an off site aid. Police report that reporting neighbor has been known to make false EMS activations in the past, stating, "When she gets like this she wants to be a good Samaritan." Based on historical and physical exam medic can find no reason to warrant transport against her will. Medical control contacted and based on medic report agrees. Refusal created, signed by pt, witnessed by PD. Pt reminded to drink plenty of fluids and to reactivate EMS (Call 911) should she feel unwell in any way.

No transport.

A couple of things about writing PCRs. You may see that there is a lot more to this report than simply medical stuff. The reason being is that when I saw the neighbor, and then after just a few minutes with the patient, I'd decided that I was going to allow her to refuse if she still wanted to after my assessment.

I also knew that honoring her wish to stay home, as a patient with special needs, was almost certainly going to get me jammed, and possibly fired when this PCR hit QA/QI. Not because I believed that I was wrong, but because I knew what every other medic at this service would have done.

I assumed that they were going to come unwound based on the liability of leaving a special needs patient at home, but was unwilling to, (what I believe would have been violating her rights), brow beat her into my ambulance to cover my ass. which I certainly could have done, as I can do with any child.

So you can probably see that my PCR is slanted in that direction. I don't believe that there is anything wrong with that as the decisions being made here were not strictly medical but involved the thought process involved when I made my decisions so I tried to paint the picture that the girl cared for herself all the time, seemed to be doing a fine job of it now, and shouldn't be mugged simply because the drunk neighbor wanted to hang out with the cops and firemen.

Not to be confused with Lying on a PCR of course, which I couldn't be more opposed to...

Anyway, it's not pretty, and it's far from perfect, and the smart providers here can say more in half the space, but that's the way I do it, give or take a bit...

Dwayne

[Bieber]

Dwayne, that was an excellent PCR brother. Seriously, reading that has made me rethink the way I write my own PCR's. Thanks for sharing that with us, man.

[Kiwiology]

Interesting, I notice you blokes like to write oodles, but then again you can get sued at the drop of a hat whereas we cant

On the contrary we are told to keep it short and relevant, the hospital doesn't want to read a novel

[EMTDenny]

Where I work right now, I know a few officers who pull some overtime working as security at the hospital. I will ask them about writing a PCR.

Dwayne, that is one hell of a PCR man!! Can that really all fit on the report?? Other than that it was fun reading it.