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



## Mattyacks (Apr 28, 2009)

Ok i just got my emt certificate.....In class my teacher pretty much showed us what a pcr looked like.....thats it.....didnt really touch on how to write one. Anyone have a routine they do for writing... pleaase share


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## CAOX3 (Apr 28, 2009)

Paint the picture, like they were standing in the street with you.  If it takes you three sentences or three pages.

As far as the format you use, thats up to you, there is SOAP, CHART and a few others, its personal prefrence.

You want to be able to pick up that run form in four years and know exactley what happened.  Ive been to court on more then one occasion, remeber if you didnt write it, it didnt happen and that couldnt be more truthful.

When I started I asked some of the more experienced providers if I could have some of their run forms to learn from.

You will find your way as you go.

Good luck.


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## Scriptor (Apr 28, 2009)

I suggest writing down vitals first, so as to not forget them.  All the technical stuff (service, truck number, date, EMT name & No.) can wait to be done at the end.  No sense wasting memory on stuff like that when you have to be as accurate as possible on the important stuff (vitals, the narrative, etc.).  Don't panic and dont sribble.  I suggest looking into a writng class if you're not very familiar with narrative writing.


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## JPINFV (Apr 28, 2009)

Scriptor said:


> I suggest writing down vitals first, so as to not forget them.  All the technical stuff (service, truck number, date, EMT name & No.) can wait to be done at the end.



Alternatively, all of that can be written on the way to the call.


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## exodus (Apr 28, 2009)

JPINFV said:


> Alternatively, all of that can be written on the way to the call.



That's usually what we do.


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## apagea99 (Apr 28, 2009)

That's odd to me. Our instructors pound the CHARTE method into our heads over and over. We have to fill out paper versions for every call on every clinical ride, and they become part of our grade.


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## exodus (Apr 28, 2009)

apagea99 said:


> That's odd to me. Our instructors pound the CHARTE method into our heads over and over. We have to fill out paper versions for every call on every clinical ride, and they become part of our grade.



We use chart, Which ends up being HART because we have a c/c field. And for trauma we use iChart

Incident
Chief Complaint
History of Call
Assessment
Rx (treatment)
Transport


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## Mountain Res-Q (Apr 28, 2009)

Mattyacks said:


> Ok i just got my emt certificate.....In class my teacher pretty much showed us what a pcr looked like.....thats it.....*didnt really touch on how to write one.* Anyone have a routine they do for writing... pleaase share



Not part of any EMT curriculum that I know of.  It should be the responsibility of the Ambulance/Fire Service you work for to teach a newbie how they want it done so as to protect your but and there.  I had an FTO that was so sue-scared that he taught me to CYA more than most.  And it helped.  I know teach the newbies at the Snow Park the same way since no one I have ever seen come out of an EMT course even knows what a PCR is.


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## Epi-do (Apr 28, 2009)

Documentation should have been covered in class, and it sounds unfortunate that not enough time was devoted to it in your case.  As previously mentioned, make sure you paint a picture, regardless of the format you use and if you don't write it, it didn't happen.

The best advice I can give you is PRACTICE, PRACTICE, PRACTICE!!!  The more narratives you write, the easier it will become.  You will develop your own flow to what you write, but the basic format should be the same for each PCR you do.  It's just the details specific to that incident that will vary.

Finding out if your employer has a preferred method they want you to use is a good place to start.  Then start reading other people's PCRs to see how they do it.  Next, practice writting your own.  Use the info from another run sheet, or completely make up a patient - it really doesn't matter.  Once you are done with the practice PCR, ask someone to read it.  If the scenario is made-up, verbally tell them what was going on so they can compare that to what you wrote.  Most people should be willing to help you out so you can develop good report writing skills.  And remember, no matter how long you have been doing this, report writing (like so much else in EMS) can always be improved upon, so never miss an opportunity to learn how to do it better.


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## Ridryder911 (Apr 28, 2009)

Anymore you throw away CHARTE, SOAP, HART, whatever ... As most are going to e-PCR's with a designated format of body check lists. One can still place a narrative in what format they choose, but will be duplicating most of it over. 

R/r 911


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## exodus (Apr 28, 2009)

A lot of services still use paper pcr's... So it is still important to learn that.


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## Ridryder911 (Apr 28, 2009)

exodus said:


> A lot of services still use paper pcr's... So it is still important to learn that.



Hopefully, most will have orientation process of exactly how and what to document. I briefly teach charting methods such clearity, SOAP, etc.. but each own surface should have its own policies in regarding charting and approved medical abbreviations, billing practices; so it would be near impossible to teach all the methods. 

R/r 911


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## Sasha (Apr 28, 2009)

Mountain Res-Q said:


> Not part of any EMT curriculum that I know of.  It should be the responsibility of the Ambulance/Fire Service you work for to teach a newbie how they want it done so as to protect your but and there.  I had an FTO that was so sue-scared that he taught me to CYA more than most.  And it helped.  I know teach the newbies at the Snow Park the same way since no one I have ever seen come out of an EMT course even knows what a PCR is.



Are you kidding? YES report writing should be part of a curriculum. Not any specific format like SOAP or CHART or what have you, but how to write a decent narrative should be part of an EMT curriculum. As one of the news threads pointed out in a blaringly obvious way, documentation is so important!


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## DrankTheKoolaid (Apr 28, 2009)

*Re*

This person seems to be new to EMS and before this thread turns into a debate somebody should actually answer his question.  
Thre are many formats that you can use for writing a chart.  And like some said, services are trying to transition to computer generated PCR's, which have check boxes for alot of the needed info.  

My suggestion would be to learn how to write a complete narrative that is both clear, concise and paints an accurate picture of the incident.  Remember that someday down the road your chart may end up in court, and if isnt written it wasnt done.  After learning this method you can adapt it to whatever service suggested PCR program.

Ive used the modified SOAP method my entire career so cannot speak for any others.  There are a ton of books out on the subject that you can get online.  Ill give you a rundown though.

You should always start with your "unit name" paged/ received phone call etc etc to respond to "blah blah".  Then note any further information you receive en route or if you request additional units.

 Then comes the what you see/hear/smell on scene along with what the patient tells you and how where you find the patient, and how they were transfered from wherever they were to your gurney and into the ambulance and the reason for this is payors tend to not want to fully reimburse for somebody that was able to walk under there own power.  So i always write assisted to gurney, unless they were actually carried, sheet dragged or whatever and document if any belongings were taken with them. 

Next would be your PX, PE, ROS or whatever you prefer to call it

Next would be your TX such as patient splinted, how they were positioned on the gurney, VS as noted, medication given etc etc and the response if any to your treatments.  

The rest of the narrative should reflect any other changes in your patient during transport along with a note stating who you give your radio report to along with whether they had questions/orders.  

Then something along the line of Blah Lah arrived SOSO ED and patient then transfered with/without belongings to ED bed A with full report given to whoever you gave it to.  


Not only will chart satisfy any service, it will be able to jar your memory in court if it ever happens.  Be it a patient care issue or consumer lawsuit or whatever. 

Like others have said though there are alot of differant styles to choose from.   Pick what suits you and master it.


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## Mountain Res-Q (Apr 28, 2009)

Sasha said:


> Are you kidding? YES report writing should be part of a curriculum. Not any specific format like SOAP or CHART or what have you, but how to write a decent narrative should be part of an EMT curriculum. As one of the news threads pointed out in a blaringly obvious way, documentation is so important!



 Sasha, I know how much you like to fight over your misunderstadings, but pay attention...

Every agency has thier own format for PCR's and such.  Yes, proper DOCUMENTATION should be and is touched upon in basic, but how in the hell can an instructor tell you how to fill out any paperwork that tends to be agency specific.  Ambulance, Fire, Ski Patrol, Hosptial, First Aid Stations, Correction Facilities, Casinos, etc... each will have their own type of PCR and what they are required to have on it beyond the basic run down of your assessment/care; and no two Ambulance or Fire (etc...) agency will be the same.  When hired by an agency they typcially run explain to you how paper work is handled for that agency.  Proper documentation is vital in our line of work, but I haven't met anyone whose 150 inadequate hours of EMT were robbed by an extensive course in paperwork; that would be a waste of time!  The OP was commenting on how they wasn't taught much on paperwork in EMT classes and I agreed that this is usually the case... what is to argue about?


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## reaper (Apr 28, 2009)

Becaue any good EMT class will teach you report writing. You should be required to fill out a PCR on every clinical pt you see. That is how you learn. Does not matter how different agencies write their PCR's. They are all basicly the same. You learn how to write them well, then you adapt to other ways.


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## Sasha (Apr 28, 2009)

My class concentrated on SOAPs, we had to have so many done by class final done or we were not allowed to take the final and failed the class. 

One positive thing i can say about my class, we all left knowing how to write reports.


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## medicdan (Apr 28, 2009)

I'll add a caveat to this.
I had been writing narratives my own way at work (urban private), including details that CYA, but provided little insight into patient care. I found that my college service followed a rubric with their reports-- each was laid out the same way, included the same pert (-)s, and while it seemed to be repetitive and useless, it proved helpful. 

A sample of our paperwork ended up at a meeting of state inspectors, and we received a commendation for excellent paperwork.

The point of my story was to endure the mundane and what seems to be pointless, as it will CYA, and it will pay off later.

ie. remember (+) or (-) for LOC, H/N/B pain, N/V/D, CP, DB, SOB, ABD pain, CSMs x4, Weakness, DZI, ETOH/Drugs, etc. Even if its just a scrape to the knee.

On a side note, we have some funky abbreviations, seen nowhere else, but appreciated by our Med Director, who reviews all calls weekly. Most notably,  ROSSU (Rest of Secondary Survey Unremarkable)...


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## Mountain Res-Q (Apr 28, 2009)

reaper said:


> Becaue any good EMT class will teach you report writing. You should be required to fill out a PCR on every clinical pt you see. That is how you learn. Does not matter how different agencies write their PCR's. They are all basicly the same. You learn how to write them well, then you adapt to other ways.



The OP wanted to know how to fill out a PCR because he wasn't really taught in his class.  I was agreeing that most classes don't go very much into that and that any agency he works for will be far more likely to teach him that.

So, if he wants to know how to fill out a generic EMT-text book PCR, read his EMT Course Textbook, there are two paragaphs on it since it isn't considered a vital bit of knowledge to past the course and become an EMT (I am not agreeing with that, but it is how it is).  Genericlly, you fill out a PCR by documenting your assessment and treatment just as it happened... if you want a more indepth answer, then that will be largely agency specific.  I could tell you how I fill out my PCR for Ambulance (as required by that counties EMSA for transport companies), which is completely different on how I do so for the Snow Park (as required by the insurence company and lawyers), which is SOOOO different than how I do ti for SAR (as required this counties EMSA standards for First Response Agencies and by OES's SAR Division).  If he wants generics than he is getting them from others, I was just pointing out that the class usually does little to prepare students for paperwork and his agency would help him out better than we could probably here.

I don't see how I said anything that is not true as to how it is in real life or said anything worth getting feathers ruffled... but whatever... -_-


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## Mountain Res-Q (Apr 28, 2009)

Sasha said:


> One positive thing i can say about my class, we all left knowing how to write reports.



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.

Don't take my statements on how it is to meant that this is how it should be.  I preach the importance of paperwork all the time.  I was investigated once on ambulance and paperwork saved my butt.  At the Snow Park at which I am a Manager/EMT Supervisor at part-time for teh last 6 winter seasons I teach an extensive paperwork course to all newbies because they often haven;t got a clue what a PCR even is.  We (The Park) get sued several times a year, and I am often called in to review 6 month old paperwork so that it can be submitted to the Insurence Companies and Lawyers.  So I make sure that all paperwork (both the medical side and the investigation side) are SPOTLESS so that my life is easier and so that no one ends up in legal trouble, especially my EMTs.


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## Sasha (Apr 28, 2009)

Mountain Res-Q said:


> 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.


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## reaper (Apr 28, 2009)

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.


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## Mountain Res-Q (Apr 28, 2009)

Sasha said:


> 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...


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## reaper (Apr 28, 2009)

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!


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## Mountain Res-Q (Apr 28, 2009)

reaper said:


> 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.


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## Mattyacks (Apr 28, 2009)

there is SOAP, CHART

What do they mean.


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## JPINFV (Apr 28, 2009)

Subject
Objective
Assessment
Plan


Chief complaint
History 
Assessment
Rx
Transport


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## Sapphyre (Apr 29, 2009)

reaper said:


> 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.


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## bassman1490 (Apr 29, 2009)

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.


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## LAS46 (Apr 29, 2009)

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*

______________________________________

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

B)


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