9 top patient care report tips for EMTs and paramedics

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:

  1. Print clearly in black ink (unless your agency requires blue).
  2. Make sure that your spelling is correct. When in doubt, look it up or change the word.
  3. Use only approved and recognizable medical abbreviations.
  4. Double-check the patient’s name, date of birth and other identifying information to ensure accuracy. If you are unsure, document the reason(s).
  5. 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.
  6. Employ a consistent method for tracking time and document travel times, treatment times and changes in a patient's condition.
  7. Be sure to describe what you see and hear (and smell, if necessary) throughout the call.
  8. Identify and attribute statements made by others, especially statements about what happened prior to your arrival.
  9. Be an artist and paint a picture! Organize a detailed sequential narrative of the call from inception to emergency room.

About the author

David Givot, Esq., graduated from the UCLA Center for Prehospital Care (formerly DFH) in June 1989 and spent most of the next decade working as a Paramedic responding to 911 in Glendale, CA, with the (then BLS only) fire department. By the end of 1998, he was traveling around the country working with distressed EMS agencies teaching improved field provider performance through better communication and leadership practices. David then moved into the position of director of operations for the largest ambulance provider in the Maryland. Now, back in Los Angeles, he has earned his law degree and is a practicing Defense Attorney still looking to the future of EMS. In addition to defending EMS Providers, both on the job and off, he has created TheLegalGuardian.com as a vital step toward improving the state of EMS through information and education designed to protect EMS professionals - and agencies - nationwide. David is a member of the EMS1 Editorial Advisory Board. David can be contacted via e-mail at david.givot@ems1.com.

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