Learning how to do a good PCR.

[DFIB]

After reading the thread I concurr with others that we are possibly talking about two different aspects of the reporting procedure.

On one hand the need to communicate pertinent information in a quick and consise way and on the other writing a report that will be defensible in a lawsuit,

I will continue to invest the additional 15 min to write the deatils because I consider it a smart investment to the future. Also beacuse when the lawsuit occurs 3 or more years latter I will need those notes to remember the call and be able to be a credible witness on the stand. I would hate to have to give sworn testimony on a three year old memory. There are some calls from last month I couldn't describe adecuately to defend.

In court if I say anything different from my report the lawyer will hang me with it.

I continue to be in favor of complete narratives.

[Wes]

Ok, I was asked to wade in on this one. First of all, I agree with DustDevil's advice about learning how to write a report from law enforcement. Those people know that EVERY one of their reports have the potential to end up in court. As such, they tend to document pretty well. I've worked in a prosecutor's office and the law enforcement reports all have two things in common -- they are written almost strictly chronologically and they describe just the facts.

Electronic PCRs are great for capturing vitals, demographics, and inteventions. I've also found that they are great at reminding you to capture certain things in your assessment findings.

As for reporting formats, I prefer straight chronological. Those reports are the easiest to read and follow.

As I've always said, ultimately your patient care may be judged by twelve people who weren't smart enough to get out of jury duty. Personally, I'd want to make it as easy as possible for them to understand what you did and why you did it.

[DFIB]

Thank you Wes.

It seems that we often end up with questions about the legal aspects of EMS and you court room experience definitely brings perspective to the forum.

Your knowledge of the legal system will be very valuable to many of us.

Great first post. Welcome.

[JPINFV]

I've worked in a prosecutor's office and the law enforcement reports all have two things in common -- they are written almost strictly chronologically and they describe just the facts.

However, unlike police, health care professionals needs to include their interpretation of what's going on. It isn't simply enough to list vital signs and exam findings. Those have to mean something as a whole, and diseases are not nearly as clearly defined or as straight forward as the penal code. Those interpretations needs to be justified in facts, but they also need to be documented.

As for reporting formats, I prefer straight chronological. Those reports are the easiest to read and follow.

Yet that is not the standard used by physicians. Why is that? Simply because chronological order isn't nearly as important as it's made out to be. Unlike the police where certain facts have to be established in a specific order (in order to do things like justifying a search or arrest, or use of force), it doesn't matter if I ask allergies before medications, or look at the abdomen before listening to lung sounds. The order of treatments provided, and the ensuing response, is the only thing that's chronologically important in terms of the care provided.

On a similar note, I've also always considered SOAP note style H&Ps to be fairly straight forward and easy when they were available on a discharge or transfer.

Personally, I'd want to make it as easy as possible for them to understand what you did and why you did it.

That's why you take the stand. I'd rather have to dumb down my testimony than look like the 2 Michael Jackson paramedics who just testified.

[ERDoc]

I have to agree with JP. There is a big difference in writing a police report and a medical report. A medical report is not a chronology but a description covering certain things such as location, quality, description, aggravating/alleviating factors. The physical exam is head to toe, not beginning to end. Your treatment course can be chronological. In the ER, this is what works best:

Chief Complaint

HPI

ROS

PMH/PSH/Allergies/FH/SH

Physical exam

ED course (diagnostics, treatments, responses to those treatments, etc)

Disposition

Follow up

Final DIagnosis

[EMTDenny]

Man I can't keep up with you guys! These are all great responses. Been busy trying to look for work! No calls yet. All in due time.

Thanks again. Keep them coming.

Denny

[uglyEMT]

Denny I skimmed through so if it was stated already i do appologize and to the others as well.

I find plain speak to work best in your narratives. Ok using Pt instead of patient is fine but other than that try plain speak. Somtimes I think the shorthand version gets confusing. BP, GCS, PEARL are all fine as well because it is standard nominclature. Some of the others get garbbled from place to place sometimes. In your written narritive always start out with Upon Arrival _____ that gives you your starting point. Note position of patient and where found (ie sitting in chair in kitchen, laying in bed in bedroom). Move on to initial findings (Pt described moderate 6/10 abdominal pain, Pt stated crushing chest pain) usually there will be boxes for vital signs so not necessary in the written portion, what interventions you performed next (accultated abdomin, placed Pt on 15L NRB) state how you transefered the patient from found position to the rig (moved patient on stretcher, used stair chair to transfer patient) state what happened after the transfer (continued treatment until ALS arrived, no further changes in Pt) state that you transfered care (transfered care to ALS) note if any incidents happened durring transport (transported to ED w/o incident, pts became combative PD notified) finally end with transfered care to ED staff.

Now for your radio narritive in route to the ED. KISS!!! Rig ___ to ___ ED. We are inbound with ___yr old M/F complaining of _____ latest vitals are _____ we have (explain any interventions quickly). ETA _____ Over

Mine usually sounds like this (generic call here)

Rig 48 to John Doe ED We are inbound with a 65 yr old male complaining of difficulty breathing. BP is 132/98 Pulse 89 Resperations 12 and labored. (sorry folks dont use O2 meters so no pulse ox given) We have him on 15L NRB ETA 5 minutes OVER. Short sweet to the point and the ED knows what to expect.

On to reporting to the charge nurse or other ED staff upon recival. Be discriptive give your SAMPLE and OPQRST and any other pertanant information thats the key there pertanant. Noticing empty liquor bottles around an altered mental state patient is pertant (doc when we got him I noticed several empty vodka bottles on the floor near him) or on your difficulty breathing patient (doc noticed alot of mold in his appartment) what isnt pertanant? Things like he misses his grandchildren or nice drapes in her appartment. Don't laugh I have been in the ED and heard those things stated during the drop off. But remember one thing sometimes everything you say goes in one ear and out the other, don't take it personally.

Making a good PCR comes with time, figureing it all out, what goes in and what doesn't. Best thing you can do to is sit down with your Crew Cheif, Captain, Lieutenant, QA Officer and go over PCRs with them. See what they concider good ones and sub par ones. When any of my members come to me with that question I usually sit them down pull out a few and review it with them. I try and keep a few great ones and a few poor ones in a file to pull out just for that. I have seen some stellar ones and ones that are shorter then one line. To this day my worst PCR I had seen....

Where the vitals go (no numbers) just the words Taken.

Narrative actually read: found patient on floor transfered to rig transported to ED

Needless to say that crew went in for some re-edamacation (lol).

Remeber this: In your written narritive document, document, document. In your radio transmission KISS and in the ED SAMPLE OPQRST and pertanant info only.

Any questions feel free to ask away

Edited October 6, 2011 by UGLyEMT

[DFIB]

Ugly

To this day my worst PCR I had seen....

Where the vitals go (no numbers) just the words Taken.

Narrative actually read: found patient on floor transfered to rig transported to ED

Needless to say that crew went in for some re-edamacation (lol).

They give love a bad name

Good post

[croaker260]

Hey all,

As an FTO, I frequently have to teach a new employees and paramedic preceptees how to do EMS Documentation. I have a number of recources, documents, etc as well as war stories of documentation gone bad. I wont torture you with all of it.

That said, as I hit the 21 year mark, I am stil a huge fan of SOAP in one form or another. For me it is the gold standard by wich I measure al naritives regardlessof format.

One of my first PO's (probationary employee...AKA a preceptee in an FTEP program) had a lot of difficulty in charting. She took copious notes on our informal discussions and then added it to a little EMS website she ran at the time (long defunct now as she passed away from cancer several years ago).

I have since copied, adapted and otherwise used what she wrote and turned it into one of the first handouts I give my new PO's. It wrks as a good starting point for discussions and teaching on charting.

The documet is attached to this post. I hope this helps.

SOAP Report Guidelines for EMS.doc

Edited October 6, 2011 by croaker260

[speedygodzilla]

My recommendation to you is find a method that works for you. Methods allow for a routine and a way to ensure that you don't forget important information.

For me I use a modified SOAP. Started off with the story and cheif complaint, including OPQRST. Moved on the objective where I put what I saw when I found them, including LOC, GCS, and ABCs. Next is asessment which for me is head to toe check box and fill in blank. Last is treatment chronological list of what I did. This is not the only way, but it is what works for me. Find what works for you and use it everytime so that you have an organized way of writing your report.