Patient care reports

[DwayneEMTP]

Man, one thing that I love about the above examples is the lack of abbreviations.. So often it seems that people believe that if you want to be one of the cool kids that you need to abbreviate your PCR (patient care report) to death no matter how much harder it makes it to read and understand....

Really great to see that the actual cool kids want a clear and productive document instead...

[Niftymedi911]

Mine is a hybrid of Chart and Soap. Med-5 responded via 9-1-1 dispatch to a female with chest pain. Upon arrival found 62 y/o female seated upright in a kitchen chair. Patient is noted to be aware of surroundings and presents with levine's sign. Patient reports that earlier in the day, while she was weeding the lawn, she developed sudden onset chest pain / Indigestion that caused her to break out into diaphoresis. She reports that she came inside and layed down thinking it was just the tacos she had for lunch. When she woke up, she reports the pain is worse and she vomited. Patient reports that she took some Tums and ASA just in case because she's had a prior MI in the past. Patient reports the pain is a 10/10, radiates to her left arm and jaw. She reports its a constant heaviness that makes her nauseous. Patient reports that she took the meds at 1400 and time of onset was 1330. She reports her cardiologist is Dr. XYZ at Madeup hospital which is a PCI hospital. Patient reports no further. Patient is placed on 4 lpm NC, baseline vitals, and given 324mg of ASA. Patient is assisted to EMS stretcher and moved to awaiting ambulance. Patient received rapid 12 and 15 lead ECG with revealed ST segment changes inferior lateral. No RVI is noted. Transport is started to Madeup hospital. While enroute patient received: SPO2, Serial 12 leads and ECG monitoring, IV NS Lock x 2 18G in bi-lat A/Cs, MS04 total of 10mg in mg increments and x 3 0.4mg NTG sublingually. Patient is noted to respond well to treatment with an overall pain decrease to 3/10 with ST segment elevation receeding but still present. No further changes were noted. Code STEMI is called and 12/15 lead ECGs are relayed to PCI. Upon arrival to ED, EMS bypassed the ED and brought the patient to cath lab where report to RN and staff is completed. No further incident. FCJ Original Document Treatment times are approximate.