Writing a
PCR
Nikhil Natarajan, REMT-P
Quality Improvement Coordinator
Beacon Volunteer Ambulance Corps.
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 PECAOx3,
PERRL, Lungs
clear = bilat.,
etc., etc.
Plan

What you
plan on doing
for the patient

For
example…..
Patient placed
on 10 LPM 02
via NRBM.
If you didn’t
write it…..
You didn’t
do it!
What to write on a
PCR




Anything that
you did for
the patient
Anything you
found during
the
assessment
How you
found the
patient
Where you
left the patient



Anything
unusual with
the call
Who started
care before
you got there
If you did it,
you should
write it.
What not to write on
a PCR


Any foul or
objectionable
language
Anything that
could be
considered
libel
– for example:
“He was
drunk”

Don’t write on
anything that
you have
lying on top of
a PCR because
it will copy
onto the PCR
because of the
carbon paper.
How do I word
objectionable phrases
into stuff I can use

“He was
drunk”

How do you
know that the
patient was
drunk. Could
have had an
AMS due to a
head injury, a
diabetic
emergency, a
stroke, etc.


“Patient had
an odor of
intoxicating
substance on
breath”
“Patient
admits to
drinking 2 40
ounce bottles
of beer.”
How do I word
objectionable phrases
into stuff I can use

“He was
high”

How do you
know that the
patient was
high. Could
have had an
AMS due to a
head injury, a
diabetic
emergency, a
stroke, etc.


“Patient admits
to using illicit
substances”
“Patient unable
to stand on his
own without
staggering and
has auditory and
visual
hallucinations”
Grammar and
Spelling

Make sure
that your
grammar and
spelling are
correct. It will
make a big
difference to
people
reading it,
including
lawyers!!


If you’re not
careful with
your spelling,
how careful
were you with
your patient
care.
Your PCR is full
of fun-filled
words.
Remember, most
of what you
need to write is
already on your
PCR
Going to court

Better be sure
that your
documentatio
n was wellwritten
– Most EMS
personnel
don’t go to
court until 4-5
years after the
call was done.

Don’t
CQI
What is it and why do
we have it?
Continuous Quality
Improvement

We have it
because we
have it.
According to
NYS DOH
Policy 96-01.


It makes us
better EMT’s
and
Paramedics
We learn
things that we
could do
differently
and more
importantly
things that we
shouldn’t do.
Some aspects of CQI



Individual
PCR Reviews
Drills and
Training
Call Audits


A system of
checks and
balances to
ensure that
proper care was
given for the
appropriate
diagnosis
Provides for
interaction with
a Medical
Control
Physician
The End

Any questions…