Addendums/Ammendments to PCR's

[thegreypilgrim]

Got a question for everyone. Say you run a call, complete all your paperwork, turn in the hospital's copy of it, and go available for service. After you leave you happen to take one more look at your PCR and realize you forgot to write something important down that you actually did. How do you make an official addendum/ammendment to it so that everyone knows what you're doing, and it's all legitimate, and doesn't look like you're just making crap up?

 

[emtzach03]

god that must be defferent for every fd or private company iwould guess. If its for medicinal error and your at your usuall er i would rewrite the whole pcr and tell the accepting nurse or doc that you had to rewrite it. If you had space on the original to write it in do so make a copy, initial and give to the er. but again im sure every region has there own protocalls

 

[thegreypilgrim]

No it wasn't for an error or anything bad. I just forgot to write something down which I thought was fairly important. I called my supervisor to ask him what to do - he said to write whatever it was I wanted to add to the PCR and mark it as an addendum, and that he would contact the hospital to sort it out. I wrote it up as an incident report as well. I would have just handed it back to the hospital myself, but we got slammed with calls throughout the day and never made it back there.

 

[emtzach03]

ok got ya. i hate writing incident reports but it would just creat the paper trail you may need if you were ever to go to court. I always found that when court came up the only pcr that was ever brought up was the one I handed in at the end of shift so as long as your pcr was filled out completely you would be in the clear. Im sure other people would have some other suggestions in this forum IM new to the site as it is

 

[spinnakr]

I think you did exactly what you needed to: called your supervisor and found out. The incident report was also a good call.

 

[guardian528]

click the addendum button and start typing

 

[medicdan]

If it were important, I would make the necessary changes to the copy you have, then give the hospital a call, speak with the treating nurse, and fax a copy of your updated PCR-- so they have a paper trail.

 

[Aidey]

click the addendum button and start typing

This. Once I finish I send it into the intertubes and it gets automatically faxed to the receiving hospital, same as the regular PRCs do.

 

[MSDeltaFlt]

Got a question for everyone. Say you run a call, complete all your paperwork, turn in the hospital's copy of it, and go available for service. After you leave you happen to take one more look at your PCR and realize you forgot to write something important down that you actually did. How do you make an official addendum/ammendment to it so that everyone knows what you're doing, and it's all legitimate, and doesn't look like you're just making crap up?

No big deal. Check with your SOP's for addendums. You can add to a legal document all the time. Just don't falsify said legal document. It may differ from service to service but generally it'll go something like this:

(Using today's date and time)

--------------------------------------------------

ADDENDUM 12/10/2009 1545hrs:

Run #, date, time: You assessed "this" on the pt, or you did "this" procedure(s) on the pt with "these" results.

--------------------------------------------------

The addendum goes with every copy of the chart. It's usually no big deal.