Documentation Patient Care Record PCR A legal document

Documentation

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.

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

Information Collected • 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 • 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

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

PCR • Some states have adopted electronic PCRs – WV is one of those states – Series of check boxes with narrative. (NEMSIS) – Won’t 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.

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?

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 • ***** DON’T JUST WRITE PATIENT REFUSED AID ****

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

Tips • Don’t 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

Discuss PCR utilized by your Agency