ppt课件-writinga p c r- revsworld（写p c r - revsworld）.pptVIP

PCR REPORTS Robby Latta EMS Instructor / Training Officer STILWELL EMS Why do we have a Pre-Hospital Care Report It was developed by a committee of EMS providers and administrators assembled from across the state for the purpose of establishing a statewide EMS data system So…what is it? The PCR is: a medical record the form becomes part of the patient record and allows for continuity of care a legal document it’s a way for the prehospital care providers to prove what treatment he/she gave a standardized record When to use a PCR A PCR should be filled out for every call, including emergencies, fire standbys, mutual aid standbys, etc. If you were dispatched for a call a PCR needs to be filled out even if you were cancelled Parts of a PCR A PCR has three copies to it. The white copy is retained by the agency The yellow copy is used for statewide data collection The pink copy is retained by the hospital for the patient’s record Writing a PCR SOAP Subjective Objective Assessment Plan Subjective What the patient told you. For example…. Patient states that she was walking down the street and walked into the light pole. Objective What you see For example…. Upon arrival found patient lying on ground next to light pole in apparent distress Assessment What you found wrong with the patient during your assessment For example….. Upon PE- pt A 0 x’s 4, PERRL,LSCTA bilaterally. Plan What you plan on doing for the patient For example….. Patient placed on 10 LPM 02 via NRBM. CHART method C= Cx or chief complaint (c/c) H= Hx or History A= Ax or Assessment R= Rx or Treatment T= Tx or Transport CHART method Cx or chief complaint (c/c) is what the patient initially called the ambulance for. Some EMTs write the actual pt’s words in quotes. Such as- ‘pt c/o “ pain in his stomach”.’ Other EMTs prefer to write the c/c objectively, such as- ‘pt c/c SSCP w/ DOE.’ Example on following slide…. CHART method Cx- c/c is pt ‘thinks’ he’s “having a heart attack”.