Writing Your Patient Care Report
When you write a PCR, pretend that it will someday be enlarged and projected onto a giant screen for a court of law and general public to scrutinize. These questions should pop into mind: How is your penmanship? How is your spelling? How well are your thoughts organized? What do these things say about you? And how do they affect patient care?
There are simple concepts and tips to keep in mind whenever you write a PCR:
- Print clearly in black ink (unless your agency requires blue).
- Make sure that your spelling is correct. When in doubt, look it up or change the word.
- Use only approved and recognizable medical abbreviations.
- Double-check the patient’s name, date of birth, and other identifying information to ensure accuracy. If you are unsure, document the reason(s).
- Double-check each checklist box to make sure that everything is covered. There’s nothing quite like noting that a glass eye is midrange and reactive to light. I have seen it done.
- Employ a consistent method for tracking time and document travel times, treatment times, and changes in condition.
- Be sure to describe what you see and hear (and smell, if necessary) throughout the call.
- Identify and attribute statements made by others, especially statements about what happened prior to your arrival.
- Be an artist and paint a picture! Organize a detailed sequential narrative of the call from inception to emergency room.
Join the discussion
The comments below are member-generated and do not necessarily reflect the opinions of EMS1.com or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.