Learning how to do a good PCR.

[ERDoc]

Denny, do you use an ePCR or do you use the standard paper PCR from NYS?

[scratrat]

ALWAYS write what they tell you in quotes. I had a little old lady fall in a parking lot breaking her hip, wrist and ankle. The store covered her bills completely. When asked what happened she replied and I quoted "I tripped over the orange parking bump thingy". Then she tried to sue for millions claiming she tripped in a pot hole. The case was thrown out based on my report.

Given the example of chest pain, this is how I was taught by a physician and I prefer it over the SOAP format. I just never liked it for some reason.

CC : CP

HPI : Pt sts he woke up at 0745 this morning with a sudden onset of mid-sternal non-radiating CP. He describes pain as "someone sitting on my chest". Rates pain 8/10. Neg aggravating or alleviating factors. He denies any PMH. He c/o associated nausea and SOB. Pt speaking in full sentences. Neg accessory muscle use. (+)Diaphoresis.

PE:

LOC : CAO x 4.

Skin : N/W/Diaphoretic.

HEENT : Pearl.

Neck : Neg JVD. Trachea midline.

Chest : Equal expansion.

Lungs : CTA c/ adequate air exchange. SpO2 96% on room air.

Rhythm : NSR s/ ectopy. 12 lead shows definitive ST segment elevation in Leads V1-V3 of 10mm.

Abd : Soft ; non-tender.

Ext : Neg edema. Full equal pulses.

Tx : HFO2 via NRB @ 15 lpm. NTG 1/150 SL x 1. ASA 324 mg PO. IV NSS (L) ACF 18g KVO. Pt reports pain down to 7/10. NTG 1/150 SL. Reporting pain unchanged. NTG SL 1/150 c/ slight relief to 6/10. CMC. Orders for morhpine in 4 mg increments repeated up to twice as necessary. MSO4 4mg IVP with significant relief to 2/10. Arrived at ED and transferred care to ER RN Mary in bed 4.

[ERDoc]

Here's some links to help you out:

http://www.wantynu.com/downloadstk/Tips%20to%20Write%20Better%20NY%20State%20PCR.pdf

http://www.thelunatick.com/ems/How%20to%20write%20a%20PCR.htm

www.defrance.org/cgi-script/CSUpload//.../PCRWritingbyRL.ppt (power point presentation)

https://docs.google.com/viewer?a=v&q=cache:nWgP9tGkjEsJ:thelunatick.net/lectures/SCEMS%2520lectures/BASIC%2520CAN/POWERPOINT/PCR%2520Documentation02.ppt+how+to+write+a+nys+pcr&hl=en&gl=us&pid=bl&srcid=ADGEEShjyqmeS5UhoICExSRH2u28lKJzRiskmUxWs0y_x8qAO6UreyE4Un-9duLAmbUXT1X7Ii-U9F66R5Lou7AC7STul03jxGClEvs-gaH5Wg1dbtmxLYpWaCHenpX39vyQS7ad1KeI&sig=AHIEtbRwc8lxY9NEpsonJqEQpWjOMiMeYA (I don't know if you can get it to work, but this is a very good presentation)

[HERBIE1]

Note to ERDOC-

I know we've discussed this issue a lot, and I never get tired of it. To me it's one of the least emphasized(in my opinion around here) skills taught in EMT and paramedic school. These programs are trying to cram as much information as possible into their programs, but I think most short change the topic of report writing and defensive documentation.

As an ER MD, what information do you find most helpful from a PCR? What are the most and least helpful bits of information we can rely to make things easier and to be most effective? I know what I've been told by docs for years, but I'd like to hear your take in this.

[EMTDenny]

Sorry for the late response Erdoc. I just got back home from a stand by with my ambulance corp. At the corp we are using a standard PCR paper. I have not yet used a ePCR.

Thanks in advance for everyone that is taking time out of their day to answer and respond.

Thanks a lot for those links ERDOC, I will surely put them to good use.

[ERDoc]

Denny, if you can get that last one to work, it is pretty comprehensive and written by an awesome instructor.

Herbie-I agree, there is not enough instruction on PCR writing in class. In both my EMT and refresher class, we never talked about writing a PCR and barely talked about how to do a radio/in-face presentation. You will find that every doc has a different preference. Personally, I find the most useful parts of the PCR to be the vitals and treatments/response to treatment. It is no offense to the EMS crews, but everything else I am going to ask and examine again. However if there is a change in the exam it is helpful to know (ie asthmatic that improves with nebs and by the time I get to them they are clear, I know what their starting point was). As for radio reports, I like them short and sweet. All I really want to know over the radio is if I need to set up for a sick pt. Some of the local radio reports drive me crazy. Observe:

EMS: "Hospital X, Hospital X, This is Amublance Y, Paramedic John Smith with a priority 2 pt report. How do you copy?" Personally, I like the Xerox machine we have, but I digress.

Us: "This is X, go ahead."

EMS: "Hospital X, this is Ambulance Y. Paramedic Smith bringing in a priority 2 pt. We have a 33y/o male with chest pain that started at 6am. It feels like the same pain he had when he was diagnosed with GERD 2 months ago. He hasn't taken any of his pepcid because he doesn't have the money. His 12 lead shows a normal sinus rhythm with a rate of 88. There are no ST or T wave changes. His BP is 124/70, pulse 88, respiratory rate 14, pulse ox 98% on 2 liters nasal canula. We haven't given him anything since he says it's just like his previous GERD. He has an IV in the left AC, KVO. Do you have any additional orders or questions?" At this point I have already moved on to the next task on my list. It is not to put the EMS crew down. It is good that they are getting a full hx, etc, as they should. All of the information is important, just not necessary over the radio.

Us: "Nothing further, you're expected. Hospital X clear."

EMS: "Ambulance Y clear of the hospital channel, going back to dispatch."

There is lots of stuff there that is not needed over the radio. Like I said, keep it short and sweet. Think something like:

EMS: "Hospital X, this is Ambulance Y."

Us: "Go ahead Ambulance Y, this is Hospital X."

EMS: "We have a 33y/o male c/o chest pain. He says it feels like his previous GERD. His vitals and EKG are stable. Do you have any other questions?"

Us: "Nothing further. See you when you get here."

When you get to the hospital and are going to turn over care, the first presentation would be appropriate since you are turning over care at that point. Another thing that I find helpful more often than you would think are your response, on-scene, etc times.

[Vorenus]

Could you guys post an example of your (or any US-based) form of a PCR - I don`t mean what you actually write in it, just the layout of your protocol (only if you are allowed to oviously), I´d be really interested.

A (really great and nice, not that it would matter, but still ) Doc told me once: "You`ve only found and did what you`ve put in writing!"

In my opinion, propably the best way to sum up this topic.

[HERBIE1]

Denny, if you can get that last one to work, it is pretty comprehensive and written by an awesome instructor.

Herbie-I agree, there is not enough instruction on PCR writing in class. In both my EMT and refresher class, we never talked about writing a PCR and barely talked about how to do a radio/in-face presentation. You will find that every doc has a different preference. Personally, I find the most useful parts of the PCR to be the vitals and treatments/response to treatment. It is no offense to the EMS crews, but everything else I am going to ask and examine again. However if there is a change in the exam it is helpful to know (ie asthmatic that improves with nebs and by the time I get to them they are clear, I know what their starting point was). As for radio reports, I like them short and sweet. All I really want to know over the radio is if I need to set up for a sick pt. Some of the local radio reports drive me crazy. Observe:

EMS: "Hospital X, Hospital X, This is Amublance Y, Paramedic John Smith with a priority 2 pt report. How do you copy?" Personally, I like the Xerox machine we have, but I digress.

Us: "This is X, go ahead."

EMS: "Hospital X, this is Ambulance Y. Paramedic Smith bringing in a priority 2 pt. We have a 33y/o male with chest pain that started at 6am. It feels like the same pain he had when he was diagnosed with GERD 2 months ago. He hasn't taken any of his pepcid because he doesn't have the money. His 12 lead shows a normal sinus rhythm with a rate of 88. There are no ST or T wave changes. His BP is 124/70, pulse 88, respiratory rate 14, pulse ox 98% on 2 liters nasal canula. We haven't given him anything since he says it's just like his previous GERD. He has an IV in the left AC, KVO. Do you have any additional orders or questions?" At this point I have already moved on to the next task on my list. It is not to put the EMS crew down. It is good that they are getting a full hx, etc, as they should. All of the information is important, just not necessary over the radio.

Us: "Nothing further, you're expected. Hospital X clear."

EMS: "Ambulance Y clear of the hospital channel, going back to dispatch."

There is lots of stuff there that is not needed over the radio. Like I said, keep it short and sweet. Think something like:

EMS: "Hospital X, this is Ambulance Y."

Us: "Go ahead Ambulance Y, this is Hospital X."

EMS: "We have a 33y/o male c/o chest pain. He says it feels like his previous GERD. His vitals and EKG are stable. Do you have any other questions?"

Us: "Nothing further. See you when you get here."

When you get to the hospital and are going to turn over care, the first presentation would be appropriate since you are turning over care at that point. Another thing that I find helpful more often than you would think are your response, on-scene, etc times.

Thanks for the reply doc. Pretty much the standard response from every doc I've ever asked or worked with.

The problem is, if we use the same base station, with the same person, with the same level of training on the radio, it would be easy to tailor a report to the likes and dislikes of the person. Rarely happens- we could get a brand new telemetry nurse, a 1st year resident, a seasoned ER nurse, or an attending physician. It's all about who's free to answer the radio. I agree about short and sweet- especially in a busy system. Maybe someone is waiting for me to finish my abdominal pain report and they have a STEMI- just common sense. I also don't think it's pertinent to include the fact that a patient with a STEMI had a tonsilectomy at 3 years old, and the fact that my patient takes multivitamins and is allergic to strawberries. It's just common sense to me.

We do have a protocol that allows us to give an abbreviated report for a routine, stable patient, but too often the person on the radio does not let us follow that protocol. The worst offenders? Residents or ER fellows who are taking their turn answering the radio.

Honestly, if I were in charge, I would mandate the absolute most basic radio report. Chief complaint, vitals, pertinent interventions, destination, and ETA. With that information, the ER knows if the person is sick or not, stable or not, and what type of bed to prepare if possible (OB, critical care, ortho, ENT, trauma, etc.) What else do you really need from a prehospital report?

[DFIB]

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.

[DwayneEMTP]

Interesting, I notice you blokes like to write oodles, but then again you can get sued at the drop of a hat whereas we cant

On the contrary we are told to keep it short and relevant, the hospital doesn't want to read a novel

Not blokes, really, as I'm guessing that most like to keep theirs shorter. I just don't see the point really, in being to brief, if I'm not backed up on calls.

And I'm not sure how it works there brother, but here, I doubt anyone of note will ever look at my PCR. They'll take my report over the radio, coming in, 15 secs or so, and then my hand off at the hospital, 30 secs at longest most times, but I haven't even written my PCR most times before patient care is well under way. I'll give em a copy, they'll stuff it in a file, unless something goes wrong and they need to review...and that will be that...

Dwayne