Documentation

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Documentation
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Patient Care Record (PCR)

• A legal document that serves as a record of all
  aspects of care that your patient received from
  the time of dispatch to the arrival at the
  hospital.

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PCR

• Accuracy is paramount because this document
  serves the following six functions
• Continuity of care
• Legal documentation
• Education
• Administrative information
• Research record
• Evaluation of quality improvement

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Information Collected

• Administrative Information
• Time of incident
• Time of dispatch
• Time of arrival at patient
• Time left scene
• Time arrived at hospital
• Time care was transferred
• Name of who transferred care to
• Patient Demographics

• Patient Care Information
• Chief complaint
• LOC/AVPU/mental status
• Vital signs
• Initial assessment
• Age, Gender
• Care rendered
• Response to treatment
• Observations at scene
• Final patient disposition

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PCR

• Some PCRs, addendums, or other attachments are
  hand written documents. They should be consistent
  in the following
• Clear penmanship
• Neat appearance
• Concise information
• Spelling and grammar

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PCR

• Some states have adopted electronic PCRs
• WV is one of those states
• Series of check boxes with narrative. (NEMSIS)
• Wont allow incomplete documentation because of
  mandatory fields that must be filled in.
• Either a print out of PCR or a drop sheet must be
  left at hospital for continuity of care.

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Narrative

• Arguably the most important section of the PCR
• Paints a picture of the incident
• Observations of scene
• Initial patient disposition
• Assessment findings
• Treatments rendered
• Reassessment after treatment
• Final patient disposition
• Think while writing a narrative If I read this
  document 5 years from now will I be able to
  understand what happened?

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Refusals

• Refusals result in the majority of EMS
  litigation
• Use the narrative to thoroughly describe
  circumstances surrounding incident
• Describe incident
• Document any complaints and assessment done
• Document refusal
• Document patient capacity
• Document explanation of risks and benefits of
  care vs refusal
• Document patient understanding
• Explain that they can call back or seek treatment
  somewhere else if needed.
• Describe any precautions taken
• Made sure a family member was with patient
• Advised patient to contact physician
• Collect signatures of patient and witness other
  than crew members
• DONT JUST WRITE PATIENT REFUSED AID

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Narrative
Use non-judgmental description of events

• Appropriate
• There was an odor of alcohol around patient
• Patient reported drinking alcohol today
• Child had multiple bruises in various stages of
  healing

• Inappropriate
• Patient was drunk
• Child had signs of abuse by parents

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Tips

• Dont use jargon that is only understood by
  members of your agency
• Only use approved abbreviations
• Spelling counts
• Remember these documents may be read by
  individuals that are not Health Care
  Professionals
• Billing agents
• Attorneys
• Patient or family of patient
• Data entry personnel for research purposes

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Discuss PCR utilized by your Agency