# Pcr



## Cup of Joe (Aug 9, 2011)

A little interested to how people here do it:

I was told that you have to hint on your PCR that the patient is intoxicated or had been drinking, but can't write blatantly that the patient is intoxicated.

If you have a patient who is acting intoxicated (clearly) and/or you can smell alcohol on their breath (lets say its strong, like a .5 liters of Jack Daniels strong), how do you write that on your PCR, if at all?

Also, if the patient says how much they've had or says they're drunk, can you then write on the PCR that the patient was drinking?

EDIT:  Does how you write it change if you can get a BAC from a police officer (if on scene)?


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## DesertMedic66 (Aug 9, 2011)

I just say it like it is. "ETOH on the patients breath." "patient states that he is drunk". "PD did a BAC and the results came back at .5." If the patient is acting like they are drunk then I put "possible ETOH". Or if there is beer/liquor bottles on scene "patient is possible ETOH with beer/liquor bottles on scene around the patient".


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## Handsome Robb (Aug 9, 2011)

Everything needs to be objective. Don't ever put your opinion in a PCR, if it goes to court, you will get torn apart. 

When it comes down to it there are medical emergencies that can make a patient act intoxicated, so you need to cover all your bases. 

If you want to really get technical ETOH has no smell and if a lawyer is good they will have an expert witness to attest to this. 
'pt states he drank 3 beers' 'observed multiple open containers within the pt's car' 'pt has unsteady gait' 'pt has slurred speech' 'police report portable PBT reading of .xxx' 

No opinions, just facts!


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## nomofica (Aug 9, 2011)

I have seen far too many  hypo/hyperglycemic patients brushed off as ETOH (and I have seen far too many of these written as fact with no proof). I haven't dealt with any other situation where either ETOH or hypo/hyperglycemia were not true but pt still appeared ETOH so I'm not sure what else mimics the same signs/symptoms.

Either way, it's ridiculous that BGL/patient hx gets ignored and passed off as ETOH. 


As for the PCRs, I make it rather objective "possible ETOH" (if not known), "ETOH-like signs/symptoms" (again if not known), if known (ie breathalyzer test conducted) "pt ETOH", or "pt admitted to ETOH" if it's obvious and they say so.


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## mcdonl (Aug 9, 2011)

Our system makes it easy.... 

We have the following synoptic data fields (You can choose more than one):

A - Pt Admits using drugs/alcohol
B - Pt Denies using drugs/alcohol
C - Drugs or Drug paraphernalia on scene
D - Smell of alcohol present

Then in the narrative you just state what matches your findings the the synoptic data fields that are listed above.

If you chose A, you could put "Pt indicated he had been using ETOH"


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## Sam Adams (Aug 9, 2011)

It's easy when they admit it.

"Pt admits to consuming alcoholic beverages"

But also: strong odor of alcoholic beverages on his person, red/ glossy eyes, slurred speech, unsteady gait,  multiple witnessed falls, unable to standup and/ or support his/her own posture etc.

edit: you have to be sure to do a very good exam on them. I assess their blood sugar, a stroke assessment, and a trauma assessment and thoroughly document them all on the PCR if I even get a hint it's going to end up in court.


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## rmabrey (Aug 9, 2011)

In my differential diagnosis I always put ETOH about him/her. In my narrative ill document how much they had to drink if they admit it. If they dont admit it, i repeat DD


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## StickySideDown (Aug 9, 2011)

I'm always sure to do a full assesment on someone I believe to be intoxicated.

As for the PCR, if the PT says he was drinking or is drunk put that in there. PT stated "I am drunk" "I have been drinking" etc. 

If not I will put "Smell of ETOH on PT's breath". "PT was acting as if he or she was intoxicated" . 

I don't hit around the bush. IF your never sure about what t put in a PCR be 100% honest, like you should be anyway. Just say it.


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## Tigger (Aug 9, 2011)

jcalNYC said:


> A little interested to how people here do it:
> 
> I was told that you have to hint on your PCR that the patient is intoxicated or had been drinking, but can't write blatantly that the patient is intoxicated.
> 
> ...



If the patient tells you that they are experiencing pain in their abdomen, you can right that down right? It's not like you have to prove that they have pain to write it in your PCR. If the patient tells you something that is related to their condition, right it down!


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## phideux (Aug 10, 2011)

mcdonl said:


> Our system makes it easy....
> 
> We have the following synoptic data fields (You can choose more than one):
> 
> ...




Our charting system uses almost these same things in a drop down box. I also put in the narrative that patient appears CSAI.
C- condition
S- simulating
A- alcohol
I- impairment


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## clibb (Aug 15, 2011)

jcalNYC said:


> A little interested to how people here do it:
> 
> I was told that you have to hint on your PCR that the patient is intoxicated or had been drinking, but can't write blatantly that the patient is intoxicated.
> 
> ...



If the patient says they are drunk or have been drinking, then I will ask them how much they consumed. In my PCR it will say "Pt stated that he/she drank 14 beers and 4 shots of Jack Daniels earlier in the evening. Pt states 'I'm just drunk'." Or "Patient had hints of alcohol on their breath."
If you get a BAC from a Police Officer, then just write "Police got BAC on scene which was ___." 

I live in a college town so we run drunk calls all the time and I work weekends.
You should document all the medical conditions that you ruled out on the patient in order for them to "appear" intoxicated. Such as BGL, SPO2, oral temp, vitals, etc. Patient medical history, allergies, medications and the quantity of alcohol or drugs that the patient admitted to.


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