Documentation

OK, so I've been out of hands on patient for a bit. Now that I've returned I've noticed that my PCR writing is to say horrible. I was wondering if there are PCR writng templates/models/PDF that I can follow to get better at writing my notes

I don't like to use templates persay, but I structure my reports as followed and get good feedback from the multitude of QA/QI folks that review my charts.

A subjective section: What you were told on scene, by whomever. Conclude with pertinent negatives if that is an expectation. Also the place to
include pertinent meds as well as a medical/family/social history. For some this might be the HPI (History of Present illness).

An objective section: A review of systems (Skin, HEENT, Chest, Abdomen, Back, Pelvis, Extremities) and the results of a neuro and mental status assessment. Some PCR programs might have a seperate tab for this, avoid repeating yourself.

Some sort of differential diagnosis.

A section regarding the course of your patient contact, to include treatments and their effectiveness along with how the patient was moved. This might be better included in a flowchart or activity log if that's how your software is setup.

Without reinventing the wheel, why not check out these sources?

I use a format nearly identical to this. Once I got used to it, it flows pretty quickly and it's gotten rave reviews from our QA and ER docs.

Same. I also add in “accident dynamics” above the subjective for traumatic events. Also allows me to copy-paste findings and interventions quite easily.

A simple chronological description of events also works.

As a QI manager, I’m not sold on any particular charting method as long as it paints a decent clinical picture of the dispatch, subjective/objective event details, patient care and handover.

If I had to write a complete patient care report from scratch with, quite literally, a blank piece of paper, I would probably do something very similar to an H&P note or a SOAP note. All charting methods will have some strengths and their weaknesses. They're all a compromise and that's OK, as long as you recognize the weaknesses the charting method you use.

Currently at work, we do Chart by Exception. That's all fine, well, and good because in theory if there's not a problem with a given system, it's OK. Here's the big issue with this: when your patient literally has nothing wrong with them (all findings are normal), your chart would be nearly completely blank. So... did you actually assess your patient? That's the problem I have with CBE. Therefore I don't really use it.

I'd actually "write" longer notes if I 1) had the time and 2) I could use voice dictation. As an EDRN, I rarely have the time to sit down and chart as in-depth as I'd like to and since we don't have voice dictation software on all workstations for all users, I can't speed up that process from any of the workstations. I'm a reasonably decent typist but with good software and a fast computer, I can dictate "stuff" nearly 3x faster than I can type.

Now that my rant is over for the minute... What I suggest you do is look over the various charting methods, look at the charting method your employer requires you to use, and then take a good look at which method is going to likely be the most efficient for you. Another thing you'll have to learn is how to "store" the info for your charting in your head so you can pretty much dump it into your chart later. At one point, I could literally tell you nearly everything about a patient, except specific labs and exact VS (I'd write those down) and then dump it onto my chart and once all that's done, I'd pretty much forget those details. I got to the point of taking simple notes for timeline purposes and later reassemble it into a chart...

Once you get good with a given charting method and you're using it consistently (and it has to be able to paint a clinical picture of the patient), you'll find that the "pieces" of charting almost fall into place easily. The one thing I'm not a big fan of is "double charting" stuff. In very simple terms, I won't chart on something in my narrative that isn't already charted elsewhere where "it" has a time-stamp associated with it unless doing so is necessary to call specific attention to that item because it's a pertinent positive or negative finding and I need that to highlight why I did or did not do something. I also don't care much about billing per se, but I also don't participate in fraud. So, while I may write an activity using specific phrasing, it's to avoid having my chart kicked back to me for "adjustment" because the billers want something else said to justify a given report. As an example, a former employer wanted us not to use the word "gurney" in reference to our own gurney because we were getting stuff kicked back to us denied because "gurney" meant "gurney van" trip and that's clearly non-medical... so we used "cot" or "stretcher" or something like that instead. Those "gurney" kick-backs got paid anyway, but it took another round of billing and that just wasted time. I will not, however, write something that isn't true just to "justify" something being billed out just because that gets us paid... that's fraud. It can be tempting to do, but don't do it. I'd rather keep my license... If a run can't be billed out because of something I wrote, so be it. I'm not going to amend that chart to make it billable if I can't do so without committing fraud in the process.

Sorry... I digressed into another rant.

Get familiar with a charting method, don't "double chart" if you don't have to, and always tell the truth, even if it gets you into trouble. The "lie" can get you into even more trouble, more than you want.

I love the chart by exception method. When I first started EMS, it was long narrative format and if you did not list it, then it did not happen and/or it gave a hole in the story wide enough for any QA Officer or Attorney to drive a truck through.

Now, the mentality is everything is normal unless stated otherwise (this does not mean we do not chart some normals such as LS or Bowel Sounds, etc). So much easier and quicker. And yes, it now places a larger burden of proof on any QA or Attorney to call into question that something was not assessed. Do some providers abuse that system, yes of course, it is gonna happen in any system, any format. You will always have halfarse providers or the proverbial pencil whippers. Guess this is where Veracity and Integrity come into play...and those are usually not behaviors which need to be learned after entering the professional world...hopefully they existed long before.

akflightmedic said:

I love the chart by exception method. When I first started EMS, it was long narrative format and if you did not list it, then it did not happen and/or it gave a hole in the story wide enough for any QA Officer or Attorney to drive a truck through.

Now, the mentality is everything is normal unless stated otherwise (this does not mean we do not chart some normals such as LS or Bowel Sounds, etc). So much easier and quicker. And yes, it now places a larger burden of proof on any QA or Attorney to call into question that something was not assessed. Do some providers abuse that system, yes of course, it is gonna happen in any system, any format. You will always have halfarse providers or the proverbial pencil whippers. Guess this is where Veracity and Integrity come into play...and those are usually not behaviors which need to be learned after entering the professional world...hopefully they existed long before.

Click to expand...

While I do love the CBE system generally, if it's done truly as "Chart by Exception" when your patient has absolutely nothing physically wrong with them, you do end up with a basically blank chart, with a note stating something along the lines of "Patient assessed head to toe, no abnormal findings noted." This would be GREAT if your organization trusted you and would back you 100% if your chart was brought into question. An indication that your organization doesn't trust you that much is seeing "normal" in various parts of your assessment charts when you're supposed to be doing CBE. If it's "normal" you wouldn't be visiting that section of the chart and therefore wouldn't have to check the "normal" box.

That's why I don't use "CBE" like it should be used. I use a more hybrid system that's likely similar to yours.