# Need help with NYC PCR



## goidf (Jun 20, 2008)

Does anyone know of anywhere online I could find the fdny guidelines for writing a NYC PCR?


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## jordanfstop (Jun 20, 2008)

Hm. I'd first try your coworkers and lieutenants. 

I'm really curious if: 

you're just starting FDNY or
you went through the academy already and never got that part or
you aren't even associated with FDNY*EMS and just want to be a whacker and have some uneducated impression that everything that FDNY*EMS does is next-to-godliness.


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## goidf (Jun 20, 2008)

none of the above. I just started working for a privet ambulance service, and our PCRs go to the FDNY (as do I believe, all pcrs from NYC).  
The point is, I want to know how to fill them out to satisfy fdny (because even if my supervisors don't like it, they have nothing to say as long as fdny don't send it back).


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## firecoins (Jun 20, 2008)

read the NYC general procedures and BLS protocols.
http://www.nycremsco.org/gop.asp?intCategoryID=2


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## Jon (Jun 22, 2008)

goidf said:


> none of the above. I just started working for a privet ambulance service, and our PCRs go to the FDNY (as do I believe, all pcrs from NYC).
> The point is, I want to know how to fill them out to satisfy fdny (because even if my supervisors don't like it, they have nothing to say as long as fdny don't send it back).


Actually... if your supervisors don't like it... they can tell you to take a hike.

Aim to please everyone.


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## goidf (Jul 18, 2008)

I could start a new post for this, but wont, (so there!).
Still being new, does anyone tell me if there is somewhere I can get a list of all the abbreviations that EMT universally (USA) use? 
Is there anywhere that I can get a list of common medications, with short summary's as to why one would take them?


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## BLSBoy (Jul 21, 2008)

:wacko:


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## medicdan (Jul 21, 2008)

goidf said:


> I could start a new post for this, but wont, (so there!).
> Still being new, does anyone tell me if there is somewhere I can get a list of all the abbreviations that EMT universally (USA) use?
> Is there anywhere that I can get a list of common medications, with short summary's as to why one would take them?



http://www.geocities.com/TelevisionCity/5196/medspeak.html
Apart from the glorious memory aids from EMT class, you should know some basic meds: coumadin, lopressors, viagra, ASA, insulin, glyburide, lasix, et al. Check out common diseases such as HTN, ESRD/CRF, CAD, CHF, CAGB, if you deal with psych patients, the difference between SI and HI, as well as the laws pertaining to transport against-the patient's will.I highly recommend a field guide, I like the Allimed BLS field guide because, in the back, you can find some 300 common meds for their use. 
Do a search on this forum, there have been discussions about this before....


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## Vizior (Jul 21, 2008)

goidf said:


> I could start a new post for this, but wont, (so there!).
> Still being new, does anyone tell me if there is somewhere I can get a list of all the abbreviations that EMT universally (USA) use?
> Is there anywhere that I can get a list of common medications, with short summary's as to why one would take them?



Ok, first... I'd recommend that while learning the abbreviations is helpful, I'd advise against using them.  It doesn't take too much longer to write:  Alert and Orientated to the Present and Current Situation, rather than A+Ox4. 

Or:  Patient was complaining of crushing chest pain throughout the anterior chest, as opposed to +C/P


Secondly, on the medications, you can consider investing in one of the pocket flip guides.


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## Tiberius (Jul 28, 2008)

The format in the comments section can be as follows:
pt's age and gender; how you found the pt; pt's chief complaint; subjective/objective assessment; treatment rendered, etc. When I worked in NYC, I never had any issues with documentation.

Most importantly, remember: If you didn't write it you didn't do it.


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## Nocturnal_EMT (Aug 14, 2008)

The best thing for me was when i first started was to look over my co-workers PCR's! 
What company do you work for?


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## Bosco578 (Aug 15, 2008)

Nocturnal_EMT said:


> The best thing for me was when i first started was to look over my co-workers PCR's!
> What company do you work for?



I agree. And lots of practice PCR's....


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## Code 3 (Aug 15, 2008)

Vizior said:


> Ok, first... I'd recommend that while learning the abbreviations is helpful, I'd advise against using them.  It doesn't take too much longer to write:  Alert and Orientated to the Present and Current Situation, rather than A+Ox4.



Why do you recommend this? Not all PCR's are the same and the narrative section can be rather small. For me, the issue was always space and not really time. It would be extremely time consuming to attach addendums to every PCR, especially if you're having a busy day. The important thing is that you, as the caregiver, know exactly what your abbreviations mean and can read your report w/o any confusion. When you're in court or approached by supervisors, you are always given a copy of your report. IMO, I don't see any issues with abbreviations, so long as you can clearly illustrate what happened and what Rx was administered.


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## TransportJockey (Aug 15, 2008)

Code 3 said:


> Why do you recommend this? Not all PCR's are the same and the narrative section can be rather small. For me, the issue was always space and not really time. It would be extremely time consuming to attach addendums to every PCR, especially if you're having a busy day. The important thing is that you, as the caregiver, know exactly what your abbreviations mean and can read your report w/o any confusion. When you're in court or approached by supervisors, you are always given a copy of your report. IMO, I don't see any issues with abbreviations, so long as you can clearly illustrate what happened and what Rx was administered.



Thats usually my take on it as well. I know my PCRs have a small narrative slot, and since I was an attend only up until last night I would hate to have to do a supplemental report for every trip sheet


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## BLSBoy (Aug 15, 2008)

Vizior said:


> Ok, first... I'd recommend that while learning the abbreviations is helpful, I'd advise against using them.  It doesn't take too much longer to write:  Alert and Orientated to the Present and Current Situation, rather than A+Ox4.



Worst.
Advice.
Ever.

There is a reason that abbreviations were created. 
Use the ones approved by your service.


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## Vizior (Aug 15, 2008)

Code 3 said:


> Why do you recommend this? Not all PCR's are the same and the narrative section can be rather small. For me, the issue was always space and not really time. It would be extremely time consuming to attach addendums to every PCR, especially if you're having a busy day. The important thing is that you, as the caregiver, know exactly what your abbreviations mean and can read your report w/o any confusion. When you're in court or approached by supervisors, you are always given a copy of your report. IMO, I don't see any issues with abbreviations, so long as you can clearly illustrate what happened and what Rx was administered.






BLSBoy said:


> Worst.
> Advice.
> Ever.
> 
> ...



If you say so.  Just whenever you get a PCR pulled by a supervisor I hope that they can read it.  Personally, when I write my narratives, it only takes a seconds to add a continuation form, which gives me a whole PAGE of extra space to write.  Or how about if you have to leave a copy of your PCR at the hospital when you transfer care.  

If you have an approved list of abbreviations, then by all means use them, because then it is a good way to move faster and save space.  But if you're just using abbreviations you think might be right, then you can be misleading not only your supervisors or court if it gets pulled, but the ER staff as well as any continuing care the patient is receiving.


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## thatrescueguy (Oct 6, 2008)

If you are NY EMS provider there is a guide to writing PCR's in the Blue Book they gave you in EMT class. You can use that as a reference/ starting point.

Having said that, practice makes better. (not perfect  )


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## Sasha (Oct 10, 2008)

I hate using abbreviations, I only use certain ones, Id rather write it all out just so its easy to read/interpert by someone if they decided to sue.

But I do write very small, so the space constraint isnt much of a problem for me


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