Im a new EMT...Need help PCR's

[Sasha]

Good, that's how it should be. I fully believe that proper documentation is VITAL; I have had good paperwork save my butt and the companies for which I work more than once. But, my point still stands that most courses I am familiar with (at least out here in Central CA) do not focus on this and I can't see how they could without taking the needed time form something else in a 150ish hour class that should already be expanded to at least 200 hours.

We somehow managed to focus on report writing while doing our 110 hours and we still covered things pretty well.

 

[reaper]

That is what we are saying. Report writing is part of the curriculum and should be taught. I have worked at many agencies and different types of medical fields. Report writing does not change much. They may require specific information on their reports, but the basic report is the same.

Whether it is paper or EPCR, most of the required info is in check boxes. Writing a narrative is where you need to know how it is done. Your narrative will not change.

Some have gotten away from writing a narrative at all. They use all the electronic boxes to fill it in. I always write a narrative, even if it duplicates info. I like to make sure it is covered. Plus, I can read my report 5 years from now and know what happened on that call.

To the OP. You can read about it in your text book. The best way is to study other peoples reports. Find someone you trust and who has great report writing skills. Then study them and learn from them.

 

[Mountain Res-Q]

We somehow managed to focus on report writing while doing our 110 hours and we still covered things pretty well.

Great. Like I said, the standard Textbooks I remember don't include much in them on documentation other than the need for it. And I don't remember much instruction in this regard. My first introduction to PCRs was my first patient at the afore mentioned Snow Park in 2001. That seems to be standard out here, but I am glad some of your courses gave documentation more than a passing thought, something that any agency you work for should often focus on more.

I just think everyone misunderstood what I said originally. The OP was obviously taught along the same lines as me (lacking in documentation) and I was telling him that "Ya, it tends to be that way sometimes, but the agency you end up working for should also be teaching you how to document properly so as to cover you (and their) azz." The reasoning for the fight toward me, when everyone was basiclly agreeing is strange, but excepted from some...

 

[reaper]

A snow park may take the time to teach that, but most busy EMS systems won't. A lot of services will test you on report writing, before hiring you. They expect you to know the basics of it, You did go to school to learn that. I just don't want the OP thinking that a service will automatically teach them. They need to work on it on their own!

 

[Mountain Res-Q]

A snow park may take the time to teach that, but most busy EMS systems won't. A lot of services will test you on report writing, before hiring you. They expect you to know the basics of it, You did go to school to learn that. I just don't want the OP thinking that a service will automatically teach them. They need to work on it on their own!

Not any of the 4 Ambulance Services I tested with, including the two I was hired by (had to decide on one over the other).

Apparently some did not focus in documentation, including the OP.

 

[Mattyacks]

there is SOAP, CHART

What do they mean.

 

[JPINFV]

Subject
Objective
Assessment
Plan


Chief complaint
History
Assessment
Rx
Transport

 

[Sapphyre]

but most busy EMS systems won't. A lot of services will test you on report writing, before hiring you. They expect you to know the basics of it, You did go to school to learn that.

Hmmmmm, my school sort of covered it (as in, was covered, but not graded), it was covered more during 2 of my ride alongs (one of them handed me extra pcrs and asked me to do the narrative, the other just talked about it). But, I wasn't actually taught until I got hired. Couldn't get past training until my FTO, Training Sup, and CQI department were happy with my reports.

 

[bassman1490]

my best advice to you is watch other ppl write there pcr's and read them, take note of how ppl write them and develop your on style or the way you like writing them. and also in my agency we have are pcr's on computers does anybody else, we use the zoll program.

 

[LAS46]

Here is the format that I was shown by National Registry:

S.O.A.P.​

Subjective: Chief Complaint, what the PT tells you, history, what PD or FD tells you about the PT upon arrival.

Objective: What you see with the scene as well as the PT. Your head to toe assessment, vital signs, and any other pertinent information you see or gather.

Assessment: Your assessment or field diagnosis (Dx) of what is possibly going on with your PT.

Plan: Your plan of action, treatments and response to the Tx, and transport of the PT along with who the PT was turned over to at the hospital.

EXAMPLE:​

S/ Responded to Loaf and Jug reference "foot pain". Upon arrival found 35y/o male sitting on the curb. PT c/o pain to left foot. PT states no allergies or medications, and no pertinent, past medical Hx. PT ate lunch 2 hours ago. States he was walking when he stepped wrong and fell off the curb, twisting his ankle. Pain is located in his L lateral maleolus, radiating to the dorsal region of his foot. PT states the pain is a 4/10 and has been going on for the last ten minutes.

O/ PT is A&Ox3. Head/face symmetric, speech clear, no jvd, trachea midline, thorax symmetric, pelvis stable, no deformity to upper extremities, pms intact, no deformity to R lower extremity, pms intact. Swelling to L ankle, with ecchymosis noted. Pain on palp to lateral and dorsal regions of L foot. PMS intact. Cap refill <2sec, skin w/p/d.
Vital Signs: RR 20 nl, pulse 100 s/r, BP 120/60

A/ PT appears to have sustained possible sprain or fx with swelling and bruising to L ankle.

P/ Splinted ankle with pillow. PMS re-evaluated, good status. Ice pack applied to L ankle. Oxygen via NC at 2 lpm. PT helped to gurney, placed in fowlers position, L foot elevated. PT monitored throughout transport. Radio report given via med 4 with no question or orders. PT care turned over to Sally, RN exam room 5, without incident.

END OF EXAMPLE REPORT

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I hope this helps you get started.
Good luck in your career.

B)