ACR (comments) writing
Posted 04 April 2007 - 06:53 PM
Does any one know of an ACR writing link?My ACR's are 95% check boxes.I'm just trying to get a nice narrative down in my comments.This is how I would write a sample ACR(below).With each Patient I would change some of the info.I'm looking for a better skeleton structure.Give me all your tips and thought process on how you approach you comments section.
60 y/o male found in hospital bed with rails up awaiting txp to xyz nursing home
Pt states no chief complaints Pt is stable at this time PE revels + ABC -SOB
- JVD +PEARL =L/S =B/L - ABD pain SND NTxQUADS + PMSx4 EXT
- BLEEDING - ECCHYMOSIS - EDEMA TXP pt in POC WOI to nursing home
Sorry I could now make the actual circles around the + and - for you.
Posted 04 April 2007 - 07:40 PM
Crush injury left thumb.
Charting is short and sweet, get to the basics and only the basics. On your example is it necessary in your system to mention the pt was in bed and the rails were up? Also do your charts have separate areas for such things as your PE, if so why repeat it? Also in your example you never stated why the patient was seen in the hospital and what the outcome was.
What you want to do is paint a short picture of who, how, what, & when. How would I write this up, like this.
() indicate where I would use shorthand.
C1 transfer St Bobs Ed to XYZ NH. 60 y/o M, S/P fall @ NH w/ C/C ® hip pain, (-) fx per ed. Pt A&OX3 in no acute distress, PE as noted above. V.S.
B.P. 140/65, HR 65, EKG SR (without) ectopy, RR 16 U/L, SaO2 99% on room air. Non emergent transport with incident.
VS signs can be placed in appropriate boxes if available also. This is just my example, your system may be different.
Posted 04 April 2007 - 09:07 PM
....yes I have to say how I found the Pt.They start us off in transport first.They want to see if you can handel (fragile eggs).I transport the oldest sickest people out of E Rs to either nursing homes or hospice care.They die very easily if not properly transported.
They want anal reporting on the comments part.They told me....if you didn't write it you didn't do it.
Posted 05 April 2007 - 02:18 AM
CC : CP
HPI (Stands for history of present illness): Arrived to find male pt sitting on sofa. Pt reports sudden onset of SSCP while at rest at approximately 1700 this date. Pt describes mid-sternal CP radiating to (L) arm. Pt rates pain 7/10. Pt is constant. Pt describes pain as 'an elephant sitting on my chest'. Neg aggravating or alleviating factors. Pt denies any previous episodes of CP. Neg SOB. Neg N/V. Neg dizziness. Neg lightheadedness. Neg syncope. Neg H/A. Neg blurred vision. Neg facial droop. Neg slurred speech. Neg arm drift. Neg recent fever or illness. Neg recent air travel.
PE: (Stands for physical exam)
LOC : CAO x 4.
Skin : N/W/Moderately diaphoretic.
HEENT : (Stands for head, eyes, ears, nose, throat) Pearl. (Includes pain/trauma if needed)
Neck : Neg JVD. Trachea midline. (Includes c/o pain, trauma, if needed)
Chest : Equal expansion. (Includes injuries if a trauma, or lack thereof.)
Lungs : CTA c/ adequate air exchange. SaO2 98% on room air.
Rhythm : NSR s/ ectopy. 12 lead shows definitive ST segment elevation in leads V1, V2, V3, and V4.
Abd : Soft ; non-tender.
Pelvis (I include for trauma only) : Intact. Neg crepitus.
Ext : Neg edema. Full equal pulses. Neg deficits.
Back : (For trauma or pain complaints) Neg deformity noted. Neg c/o pain.
Tx : O2 via nasal @ 6 lpm. 12 lead ECG. NTG 1/150 SL c/ slight relief of CP to 6/10. ASA 324 mg PO. IV NSS lock (L) ACF 18g. Labs drawn x 3. Blood sugar 112 mg/dL. NTG SL 1/150 SL c/ slight relief of CP to 5/10. NTG 1/150 SL c/ slight relief to 4/10. MSO4 4 mg IVP c/ decreased CP to 2/10. NTG Paste 1' transdermally to (L) anterior chest wall. MSO4 2 mg IVP c/ complete releif of CP. Transferred pt care to ED RN in bed 3.
Granted, this is probably more in depth than you need, but the standard is always the same for me. I have been in depositions several times, and the way I document usually precludes me from court. If you didn't write it, it didn't happen. Not to bore you but here is a perfect example why I document the way I do.
Dispatched for a fall. Little old lady tripped over one of those concrete car stopper things in a parking because she didn't see it. Unfortunately, she really did get hurt bad. Fractured her hip, ankle, wrist, and I think something else. In my report I wrote EXACTLY what she said. "I tripped over that parking bump thingy." Long story short, the major food chain store paid for ALL of her medical expenses. She then attempted to sue for millions because she said she tripped in a pothole. After reading my chart, without me going to court, they threw out her lawsuit. I think that food chain owes me a gift certificate, but hey.....
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