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Requirements
Musts/Omissions
Documentation
Subjective v.
Objective
Assessments
Comments
Redundancy
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Acceptable /
Authorized
Medical
Abbreviations
GCS
RMA’s / Forms
Rear of PCR
Telling a Story
◦ Pre-hospital
– These are issues and
conditions the ED staff can’t see and don’t
know about. Important to document.
 Accidents – condition of car, position of patient
 Homes – condition, temperature, medical devices
 Nursing facilities – need I say more
◦ Care
– Simple…What treatment did you
provide to the patient
 Again, if it’s not visible, the ED staff won’t know
what you did
 Self treatment prior to EMS arrival
◦ Report –
As by it’s very definition:
 (noun)
 a usually detailed account or statement
 (transitive verb)
 To relate the words or sense of
 To make a written record or summary of
 To give a formal or official account or statement of
◦ Report
 Examples
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Book reports
Accident reports
Report cards
Reporters
◦ Report
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TELL A STORY
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RELAY INFORMATION
Date
(mm/dd/yr)
132186
07/18/13
Can be
completed
post call
05129
32420
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Agency Name – BSBRA
Dispatch Information
◦ Plain English – Chest Pain
◦ EMD Code – 10D3
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Call Location
◦ As specific as possible
◦ Address
◦ “IFO”, “in vicinity of”, intersection, direction,
business name, etc.
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Location Code – 5154 (Islip Township)
◦ 5100 only if unsure
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Times
◦ Must be filled in prior to leaving the hospital
◦ Call headquarters or MedCom if needed
◦ Must correlate with vital signs
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Name – Spell correctly
◦ This is what is used at triage to get pt. into
the system
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Phone –
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DOB/Age – Again, be accurate
◦ should be an emergency contact, NOT the
patient’s personal cell
◦ If you can’t do the math and figure out the
person’s age, ASK THEM
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SSN – Important for patient tracking
-
Jose Diaz
Juan Martinez
Victor Rivera
Julio Gonzalez
Maria Sanchez
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Michael Brown
Susan Smith
Tom Robinson
Frank Williams
Karen Jones
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Physician
◦ General Practitioner if possible
◦ Can write in specialists too
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Care in Progress on Arrival
◦ Self explanatory
◦ If possible, name and vehicle
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Mechanism of Injury
Extrication required
Seat belt used
Fill in and
document
accordingly
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Use the words of the patient
◦ “I fell and hurt my knee”
◦ “I thought I was going to pass out”
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Use the words of a witness
◦ “He fell down and hit his head”
◦ “She started shaking a lot”
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Do NOT write diagnosis here
◦ “Syncope”, “blunt trauma”, “diabetic”
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If patient cannot or doesn’t make a
statement:
◦ None – pt unresponsive – pt AMS
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Presenting problem
◦ Fill in circle of ALL that apply
 Cardiac related, Respiratory Distress, Pain, Other
 Head injury, Fracture, Bleeding
◦ Circle primary condition/incident
◦ Pain and Other – be specific
 L sided c/p radiating to jaw and L arm
 Nausea, dizziness, AMS
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Fill in circle of all that apply
Other: GERD, Vertigo, Gout, Anxiety, etc
Allergies and Medications
◦ WRITE SMALL
◦ DO NOT write up the side of the PCR
◦ DO NOT use up entire assessment/comment
section if the pt. eats the pharmacy daily
◦ Use continuation form
◦ “See list” - unacceptable
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Times MUST correlate with response
times!!!!!
Respirations and Pulse
◦ Rate and condition
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Blood Pressure
◦ “Palp” or “P” is acceptable – document!
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LOC
◦ How does the pt. respond based on stimuli
◦ Alert does not mean oriented
◦ 1st set of v/s should be within 1st five
minutes of patient contact – if not, document
reason for delay
 Prolonged extrication, delayed pt. contact, pt.
agitation, etc.
◦ Make every effort to obtain 2 sets of v/s,
especially if giving treatment – if only one
set, document why
◦ GCS – Glasgow Coma Scale
◦ Eye Opening (1-4)
 Similar to LOC , but different
◦ Verbal Response (1-5)
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Oriented
Confused
Inappropriate Words
Incomprehensible Sounds
None
◦ Motor Response (1-6)
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Obeys Command
Localizes Pain
Withdraw (pain)
Flexion (pain)
Extension (pain)
None
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Glasgow Coma Scale
◦ For any sum other than 15 or 3, write the
individual numbers of each assessment
above the total
◦ Eye opening – spontaneous (4)
◦ Verbal Response – confused (4)
◦ Motor Response – obeys command (6)
◦ Total = 14
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Pupils
◦ Difference between R & L??
◦ It’s okay if not assessed – document
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Skin
◦ Unremarkable means exactly that
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CUPS
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Critical
Unstable
Potentially Unstable
Stable
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Treatment Given
◦ Fill in circle to all that apply
◦ Fill in all boxes and blank lines
◦ “Other” section– PFA / ES not necessary
◦ Questions regarding specific treatments?
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Subjective
◦ Personal
perspective
◦ Feelings, beliefs,
opinions, attitudes
◦ Existing in the
mind
◦ Cannot be seen
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Objective
◦ Object
◦ Something
tangible
◦ Can be
seen/touched
◦ Measurable fact or
evidence
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Subjective
◦ What the pt. tells
you
◦ Pain, weakness,
dizziness, nausea
◦ Events leading up
to incident (onset,
duration)
◦ Treatment prior to
EMS arrival
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Objective
◦ What you observe
◦ Lacerations,
deformities,
ecchymosis,
paradoxical
breathing
◦ Knife sticking out
of pt. chest
◦ Treatment prior to
EMS arrival
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Begin telling your story
Try to be as chronologically correct as
possible
How was pt. found, c/o, onset, duration,
severity, associated symptoms,
aggravating/alleviating factors
Witness/family statements
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Continue your story with tangible
observations
Physical assessment
Head to toe
Vectored exam
Pertinent (+) and (-) findings
DO NOT use words/terms if you don’t know
what they mean!!!! K.I.S.S.
◦ Abbreviations
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May continue your assessments
Treatment (Rx)
◦ No need for redundancy
◦ Chronological
◦ Effects of treatment
 1st rule of medicine – DO NO HARM
◦ Explain your omissions/justifications
◦ Transport – pt. position, incidents/change in pt.
status, hospital choice
◦ Pt. refusal of treatment/txp – RMA
◦ Medical Control
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Disposition
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See list
Non-Hospital Disposition Codes
Southside Hospital (SSH) - 521
Good Samaritan Hospital (GSH) – 515
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Crew
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Continuation Form Used - circle
◦ In charge means technician in charge/team
leader of the patient
◦ Person completing the PCR
◦ DOES NOT mean highest ranking officer/crew
chief on scene
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Know what you are saying and
abbreviating
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SPELLING!!
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Use approved medical abbreviations
LLQ / LLR
LLQ – Lower Left Quadrant
LLR – Left Lateral Recumbant
DKA / AKA
DKA – Diabetic KetoAcidosis
AKA – Also Known As
- Above the Knee Amputation
HEENT
HEENT – Head, Eyes, Ears, Nose, Throat
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HEENT clear???
Document specifically what was checked
◦ Trauma/deformity, pupils, conjunctiva,
discharges, swelling/edema, etc
PEARL
PERRL
PERRLA
PEARL – Pupils equal and reactive to light
PERRL – Pupils equal round reactive to
light
PERRLA – Pupils equal round reactive to
light and accommodation
PMS
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Pulse, motor, sensory
◦WRONG
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Premenstrual Syndrome
◦ 46 y/o male found leaning forward in chair
c/o abdominal pain. Pt PMS intact
WNL
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Within Normal Limits
◦ WRONG
 We
Never Looked
◦ V/S wnl, trauma exam wnl, PMS wnl
◦ Unremarkable is acceptable
♂
♀
MALE
FEMALE
 The
less you write the better.
◦ Less likely to make mistakes
◦ Less likely to be questioned
 100%
FALSE!!
◦ If you didn’t write it, you didn’t do it
◦ Court / subpoena
 Be
confident in treating your
patient and documenting it
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Be able to justify any course of action
you take or omit
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Fill out a PCR for EVERY activation
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Transport
Care transfer
Cancellation (even if you don’t roll)
Stand-by
Remember to tell a story
 We are an extension of the ER
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◦ Describe the events leading up to
the transfer of care to the ED staff
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Be a patient care advocate
◦ Pt. pedigree information
◦ Treatment
◦ Speak up to triage RN / staff
Completed PCR’s