PCR Narrative writing skills

[The Hook]

Greetings!

I am looking to drastically improve my PCR narrative writing skills. Is there a web site, download-able outline, advice, a book, or any other source of info floating around on the subject out there?

Please let me know!

Thanks to all!

The Hook

[JakeEMTP]

I found a couple of sites that may help you. There are other links from there. I hope this helps you some.

http://wps.prenhall.com/chet_limmer_emerge...content,00.html

[MikeJ]

I was looking for the same thing a while back, and I found very little that was of any use.

I then asked my department's QC staff what they wanted to see on the PCRs, and that helped a bit.

[Lithium]

I've found that the more you write them, the better you become at them. Once you write a form, ask your partner to critique it (and remember, take their advice along with everyone elses with a grain of salt). Remember to always include pertinent negatives, as it implies a comprehensive assessment.

Also, the best piece of advice I can give you is to BE CONSISTENT when using short forms. I use short forms and abbreviations all the time on my ACRs, but I know exactly what they mean. I see people who interchange LOA and LOC daily for instance, and I truly believe that will come back to bite you in the butt. Develop a list you're comfortable with and stick to it, that way when when you're called into court and they ask you what you meant, you'll recall without hesitation.

peace

[kemt217]

Hey Hook,

The link Jake posted has a lot of good tips. As far as abbreviations go, our service has a list of "approved" abbreviations that are in our protocol books. That keeps people in check when writing the narrative. Do you know if your service has one of these lists also??

Have a great day!

[The Hook]

Not certain of the list of approved abbreviations. I will look. Thanks everyone for getting back to me. The help is appreciated.

Kevin "The Hook"

[docomd600]

I use "SOAP" for my narratives:

S - Subjective, what the patient tells you and this is where I put my SAMPLE (Sign/Symptom, Allergies, Medications, Past medical history, Last oral intake, Events leading up to the patient calling 911 for MOI/NOI)

O - Objective, what you see. This is where you document what you see, OPQRST, Vitals, Chief complaint, your exam of patients MOI/NOI

A - Your assesment of patients condition, always put "Rule out Possible......" How you found patient, patients attitude, etc.

P - Plan of action, what you did to help patient (splinting, O2, etc.), how the patient moved to Ambulance (stretcher or walked on their own), any improvements in patients CC, condition on arrival, any problems enroute with patient (drunk, assault, complained of severe pain), name of hospital you transported to.

I hope this helps you. I also made up my own patient stat sheet that I included information such as Protocols, BLS Drugs and doses, burn calculations, SAMPLE, OPQRST, Helicopter flyout catagory (A-D), helpful hints for terms, assesments, DCAPBTLS, normal vital signs, GLASGOW Scale, area zip codes, hospital codes and patient info

[JPINFV]

Generally I won't note anything related to my patient's history. allergy, meds, or my physical exam in the narrative. My physical exam is a part of my primary or secondary on my PCR unless I run out of room (mostly due to pertainate negatives. An example would be not c-spineing an unwitnessed fall 4 hours ago when the patient denies back, neck, head tenderness, pain, etc). I leave my narrative for how I found the patient (in bed, on gurney, waiting out in front of their house, etc), what I did to the patient (placed on 15 LPM via NRB, splint, dressed and bandaged wound, etc), any change because of it (decrease SOB, increase LOC, etc), any thing that I can't think of a place to put it and abnormal (i.e. an irregular pulse secondary to a Hx of A-Fib is different then an irregular pulse in a patient with a Hx of "occasional" PVCs and is having runs of bump-bump-skip-bump-bump-skip or transporting a suspected CVA with onset the previous night code 2 because the patient has already past the window for tPA), and who I left the patient with (pT left in care of RN/MD/staff/family/etc).

Of course an ALS PCR would be much more in depth.

[chbare]

Docomd600, I am an old fan of SOAP notes and POMR. I use a slightly modified version, SOAPE.

S-Subjective

0-Objective

A-Assessment

P-Plan

E-Eval/Re-eval

Take care,

chbare.

[Just Plain Ruff]

Get the book "The Fourth Protocol" it is subtitled how to write a legally defensible report.

Search for it on Amazon.com

If you can't find it email your addy to my email ruffems@gmail.com and I'll send it to you but I'd like ot have it back.