Learning how to do a good PCR.

[JPINFV]

If I started working on an ambulance now, I'd use a modified SOAP format while maintaining the classic SOAP formatting (i.e. not shove it all into one continuous paragraph).

http://emtmedicalstu...ing-pre-soaped/

Edited October 2, 2011 by JPINFV

[DFIB]

I wrote that report in the USA. My clinical supervisor had requested detailed reports. My EMS lawyer friend seems to think detail is the key to surviving potential lawsuits.

Down south there isn't a narrative of the patient care. PCR reports here are just a bunch of boxes to check and fill in.

Most EMT's are more concerned with detailing that they didn't steal the patients belongings than a narrative of his condition because the police will routinely pillage the patients belongings in MVC's and some EMT's do as well.

My crew does not participate in pillaging because they are handpicked for honesty and professionalism and I will have their heads if I find out. I once stopped the ambulance and left the offending EMT on the side of the road to walk home because I saw him palm a ring at an accident.

I was very disappointed that they only suspended him for 3 days. They didn't ask me to justify my action because I was ready to punch anybody that sided with the offender. They do act right when I am on call since then.

If I started working on an ambulance now, I'd use a modified SOAP format while maintaining the classic SOAP formatting (i.e. not shove it all into one continuous paragraph).

http://emtmedicalstu...ing-pre-soaped/

I like your perspective and will most likely give it a whirl and see how it works for me.

Thank you for your input

[EMTDenny]

Judging from these amazing responses I still have lots to learn with EMS!!. You guys are Professionals in my eyes!!

[Kiwiology]

This right here, makes my eyes bleed because it contains a lot of superflorious information that the hospital is not going to care about, you have to go searching for information and it's very long winded.

Here is a narrative from my first clinical rotation on the ambulance. Vital signs re not included because they were logged on a seperate sheet that I did not retain a copy of. I remember that her BP was aprox 180/90 initially and dropped to normal ranges after 5 minutes. Spo2 98. ECG unremarcable. I try to give a good narrative because it could be years if it goes to court and I probbably wouldnt remember the details. This is not given as a example put to seek a critique. So please let me know what you think.

Medic 2 is toned out at 16:57 to a unconscious female that is breathing.

We arrive to a expensive ranch house where many people are gathered on the front porch. Scene is safe. We are escorted to the living room where a young, athletic female is sitting on the couch in obvious pain. Chief Complaint There is a woman sitting next to her that sais “She fell and hit her head” “They carried her to the house” History The patient was at a company party and was riding a horse when the horse spooked and she fell on her face impacting on her forehead, the ground was hard. She denies loosing consciousness. “I did not pass out, I don’t know why you were told that I passed out”. “I stood up on my own and developed neck pain almost immediately” She was carried to the house by the carrier placing his arms under her gluteus maximus and picking her up vertically. She is taking no medications and denies allergies. Ingested a hamburger and two glasses of Coca Cola two hours ago. LMP 08-31-2001

Assesment The patient is alert and well oriented. When questioned she declared “ My name is XXXXX, the president is Obama, today is Saturday and I fell from a horse. Airway Breathing and Circulation: Airway and breathing are intact. Head She presents a bruise that is forming on her forehead and across the bridge of her nose. Raccoon bruising is beginning to form. Head presents no deformities other that the bruise. There is no liquid from ears or nose. Pupils are round, equal and reactive to light. Neck Cervical spine is tender to the touch but has no deformities, contusions, abrasions or penetrations. There is no jugular vein distention and the trachea is midline. Thorax Anterior thorax shows no deformities or pain but the patient complains of pain upon palpation of the vertebrae around T4. Breath sounds are clear and bilateral with equal chest rise. Abdomen Is soft and non tender. There is no echimosis or guarding. Pelvis is stable and non tender to palpation. Extremities. Patient complains of extreme pain in her lower arms and tingling in her fingers. Pain is 8/10 on a 10/10 scale. Pain in her thumbs bilaterally. The fingers in her right hand are in a cramped position flexed over the palm. She can move her fingers with effort and pain. Pulse, motor, and sensory function are present. Radial pulse 98, strong and rythmic.Lower extremities present no abnormalities or pain. Pulse, motor, and sensory function are present Transport. C-spine is placed while patient is sitting on the couch. The patient stands and sits on the stretcher but complains of severe neck pain when we began to lay her on the backboard. The maneuver is suspended and the patient is immobilized with the KED. And transported in the Fowler position. Patient receives oxygen via a nasal canula at 4L/min and Fentanyl 100mcg intra nasal. IV is not attempted because of the extreme tenderness in her extremities. She is transported to Memorial Herman in Katy Texas. Report is given, care is transferred with patient immobilized in the KED and signatures are obtained. Medic 2 returns to service at 18:21.

I would write this

Hx of being thrown from horse and hit forehead. Denies LOC

No PMH, NKA, no meds

O/A sitting on couch, conscious + alert

O/E airway, breathing, circ normal, bruising across forehead and bridge of nose, bilateral periorbital contusions, no CSF or bleeding ears/nose, pupils PERL, c-spiine pain upon palp but no step or deformities, pain upon palp of ~T4, abdo soft nontender no guarding, pelvis stable. Pain in lower arms. tingling in fingers and thumbs bilat 8/10, ® fingers cramped flexed over palm, can move fingers with effort and pain, pulse, motor and sensory function present. Legs/feet unremarkable, sensory and neuro normal.

C-collar, KED, transport

Below is where you would list the dosages of medicines and fluids as well as vital signs on our PRF

The one thing that stands out to me is no mention of a GCS, that's quite important esp on a head injured patient, the hospital are going to be checking it quite frequently.

Edited October 3, 2011 by kiwimedic

[Kiwiology]

Here are some tips from our Operations Manual

The format should be logical and sequential:

•• History (including mechanism of injury for trauma patients)

•• Relevant past history

•• Examination findings including primary and secondary survey

•• Treatment and response to treatment

•• Pertinent negatives ...requires judgement; e.g. ‘no abdominal pain’ is a pertinent negative if the primary problem is vomiting, but not if it is stroke.

A 3-5 word summary that best describes the overall scenario should be entered [as the chief complaint/primary problem]. For example, if the patient has a compound femur fracture then this should be stated, rather than ‘leg pain’. If confident that the patient has inferior STEMI then say so, rather than ‘chest pain’. If unable to make a confident diagnosis, describe the main problem rather than what the patient is complaining of. For example, if the patient is complaining of light headedness but the problem is bradycardia causing hypotension, then it is the latter that should go in the chief complaint.

List all known medications using generic drug names. It is not acceptable to write ‘see GP letter’.

List known allergies to medicines. N.B. Nausea and / or vomiting with opiates is not an allergy.

Do not list allergies to foods or stings.

Medicines should be recorded using the full generic name and not the brand name (e.g. salbutamol and not Ventolin)

Abbreviations are unacceptable for medicines. For example, you must write morphine, not MS.

Here are two more examples

Road traffic accident

Hx of being driver in car v. truck approx 80km/hr; trapped w/ prolonged extrication

C/C bilat femur #, L closed R open

PMHx asthma, NKA, meds ventolin prn

O/A pt pinned in car by dashboard, conscious + alert, in obvious pain

O/E airway normal, fast resp, circ adequate. No LOC, head and neck normal, no c-spine pain on palp, no CSF, PERL, no JVD or tracheal shift. Chest and ribs painful to palpate but no #s or deformity, no PTX, b/s clear good air entry. Abdo soft, non-tender, no guarding, unremarkable on palp, has impression of seatblet on trunk and abdo, no pelvic pain, no deformity or tenderness on palp, bilat femur #s, grossly deformed L femur closed, R femur open.

Once extricated, collar, scoop, covered R femur, bilat traction splint, transport, morphine + midazolam effective analgesia, pt comfortable,

PFO (pissed and fell over)

Hx tonight etoh ++, tripped and fell to ground

PMHx/allergies/meds uknown

O/A pt unconscious on footpath

O/E airway, breathing, circ normal, smell of etoh ++, responsive to painful stimuli, head normal no blood, CSF or bruising, PERL, chest and abdo normal, no tenderness or deformity felt, b/s clear equal good air entry, pelvis stable no deformity, no bleeding, normoglycaemic. Move to ambulance and transport.

Below again, is where we list drugs and fluids, vital signs/GCS etc

[Just Plain Ruff]

I would highly recommend the book "The Missing Protocol. How to write a legally defensible report"

It was originally written by Kate Dorneceau but it's also written by Denise Graham.

It's out of print but if you can find it it's well worth the premium to pay that you might have to pay on Ebay or somewhere.

I'm still looking for my copy. Lost it in a move somehow.

[WelshMedic]

Hi all,

It would appear that the threat of litigation is the reason why everyone should be writing a novella on every patient, however mundane. Whilst I can see why that would be necessary, it seems a shame that your putting all the effort in for the lawyers and not the colleagues. Believe me, in a busy ER, no-one is going to take a second look.

Now, as far as verbal reports are concerned, that's a different matter. They need to be short and sweet. Past research has indicated that the recipient will listen for about 30-40 seconds before their attention starts to wander. Thus, you have a 30-second window of opportunity to get your message across. Mmm.. when I come to think of it, the best of us could switch jobs and make millions in advertising

We use e-PCR's which are a godsend, you don't really need to think much at all, everything is prompted. My verbal reports follow this structure:

Mechanism of Injury: what happened?

Injuries found or suspected: the findings of your physical exam. (In medical patients I would also refer to the appropriate history).

Signs: the vital signs ( and whether or not they are pathophysiological in this pt.).

Treatment: What did I do and what effect did it have?

The above is all that is required for the radio report, when doing the handover at the ER then I will supplement with SAMPLE and information over the next of kin.

WM

Edited October 5, 2011 by WelshMedic

[ERDoc]

It would appear that the threat of litigation is the reason why everyone should be writing a novella on every patient, however mundane. Whilst I can see why that would be necessary, it seems a shame that your putting all the effort in for the lawyers and not the colleagues. Believe me, in a busy ER, no-one is going to take a second look.

I agree and disagree. Litigation is a huge issue and here in the US, if you didn't dot an 'i' and it looks like an 'l' you will loose your case. Unfortunately when someone has a bad outcome (even if everything was done perfectly) part of the normal reaction is to find someone to blame. Throw in the lottery ticket mentality we have here and you have a system where you need to CYA with everything. Lawyers loves to see things that aren't there. Let's say you honestly forgot to put something on your PCR because you were being leaned on by your dispatcher because there were multiple calls hanging. A lawyer will turn it around and say you didn't write it because you screwed up and were trying to cover the fact.

I can't speak for all ER docs, but I often like to look at the PCR to look at the things I mentioned before.

Past research has indicated that the recipient will listen for about 30-40 seconds before their attention starts to wander. Thus, you have a 30-second window of opportunity to get your message across.

That research was done on normal people. With ER docs, you have a 5-10 sec window before our ADD kicks in and we start thinking about the next pt, pizza or the hot nurse standing next to you. If you need our attention for more than that you need to use a key word such as intubation, arrest, elevation, hypotensive or pepperoni pie with extra cheese.

[FNGfirstresponder]

This is the best system that I have read:

http://www.emsmdc.com/pdf/documentation.pdf

[WelshMedic]

Let's say you honestly forgot to put something on your PCR because you were being leaned on by your dispatcher because there were multiple calls hanging. A lawyer will turn it around and say you didn't write it because you screwed up and were trying to cover the fact.

It's a sad world...

That research was done on normal people. With ER docs, you have a 5-10 sec window before our ADD kicks in and we start thinking about the next pt, pizza or the hot nurse standing next to you. If you need our attention for more than that you need to use a key word such as intubation, arrest, elevation, hypotensive or pepperoni pie with extra cheese.

I find that "fancy a beer to go with the pizza" does it for me...