how to practice and become proficient with pcr/radio report

wutthedutch

wutthedutch

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ive got the soap format and the radio format for emergency and non emergency.
are these formats the same for every ems company? and how can i practice or get proficient at this because its the only ems skill im lacking in. i have no problem writting down what happens but the formats show everyhing in a strict sequence of events to remember its just really complicated for me even with the guide at my side. im not sure if my company will have written or electronic pcrs either =/ not sure where to start on practicing but any advice would be greatly apreciated. merry christmas :) also if im this terrible at pcrs should i wait until ive mastered it before applying at a company? i still have a week or so before my fbi check goes through
 
JPINFV wrote a little something on documentation here.

No, it's not the same for every company. SOAP is a commonly taught mnemonics/memory aid in school and used by various agencies, but I've heard of other ones too (e.g. CHART), or some places don't even have a recommended format.
 
The first question to ask with radio reports is, "What's required?" Some areas will determine what is required by protocol of policy.

The next question is what type of radio report. Is it an "entry note" (i.e. "Hi, we're bringing you a patient") or a medical control note ("I need orders and/or help with managing this patient").

The key to entry notes is to keep it short and simple. Unit level/ID, priority level if applicable (e.g. priority 1/2/3/4. Not used everyplace and not the same as lights/sirens vs regular traffic) patient demographics (age/sex), chief complaint/specialty team needs/quick description of mechanism, pertinent information (V/S if abnormal, justification for the specialty team, anything that needs to be managed immediately on arrivial. "Lung sounds clear bilaterally" is generally not pertinent at this time), ETA.

"Local Ambulance BLS 75 en-route to your facility with a 60 y/o male with a stroke alert. Patient developed unilateral decrease in grip and facial droop on the right side approximately 30 minutes ago. BGL per patient at the same time was 90 mg/dL. ETA 10 minutes out. Any questions?"

Chances are the person on the radio isn't going to be the one you're transferring care to, and even if s/he is, you're still going to give a full report when you transfer care anyways.
 
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You'll figure it all out through practice/trial and error when you start working. Nobody is going to expect you to be good at either during your first few weeks.
 
I personally hate the SOAP format and advise all new people to avoid using it. The best thing to do is ask for example narratives from your co-workers. They can show you the narrative without any patient identifiers.

I type all my reports using a narrative style flow that takes the call from start to finish.
 
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Agreed completely with JP.

A good entry note should not last more than 60 seconds. However if you are seeking medical control, that discussion could last a great while longer.
 
WuLabsWuTecH said:
Agreed completely with JP.

A good entry note should not last more than 60 seconds. However if you are seeking medical control, that discussion could last a great while longer.
Click to expand...

It all depends on the hospital you're transporting to. Some like a short and sweet quickie, "Medic 104 inbound with a 45 year old Priority 1 COPD, on CPAP. We've got about a 5 minute ETA" Other hospitals what EVERYTHING in the radio report. Vitals, current meds, history. Blah, blah, blah...

Find out how they do it where you are and practice that.

Here's a tip. Most ER base stations have a form the nurse will fill out when a medic or EMT calls in a radio report. Next time you're at the hospital, ask for one (or grab one from the radio desk), laminate it and BINGO... Instant cheat sheet in the exact order they're writing stuff down.
 
WuLabsWuTecH said:
Agreed completely with JP.

A good entry note should not last more than 60 seconds. However if you are seeking medical control, that discussion could last a great while longer.
Click to expand...

Like n7 said it is very location specific. If we give a report for an ILS/BLS PT that's more than 20-30 seconds it's pretty much guaranteed the charge nurse is no longer listening to you plus 9 times out of 10 there will be other units on the channel waiting to give their report as well.

JP gave a good one, I'll give you one I had today:

"Good afternoon *insert facility here*, Rob on Medic xxx inbound to your facility about 5 minutes out, onboard I have a 50 y/o M complaining of general illness, last BGL was 450, all other vitals are WNL I have a 18g placed in his right hand with about 500 mL in, unless you have any other questions I'll see you inside."

ALS reports will be a bit more detailed with pertinent findings that you deem the receiving facility needs to know.
 
get with you coworkers, have them fake a call and you report it...do that as much as you can. pretend its real practice practice practice
 
n7lxi said:
Here's a tip. Most ER base stations have a form the nurse will fill out when a medic or EMT calls in a radio report. Next time you're at the hospital, ask for one (or grab one from the radio desk), laminate it and BINGO... Instant cheat sheet in the exact order they're writing stuff down.
Click to expand...

Agreed.
 
Everyone has their own style of writing paper reports/ radio reports. Read some of your coworkers reports or listen to the give the radio report. Thats pretty much how I learned, Although i never have to do them since im an EMT and technically only Paramedics are allowed to do reports.
 
feldy said:
Everyone has their own style of writing paper reports/ radio reports. Read some of your coworkers reports or listen to the give the radio report. Thats pretty much how I learned, Although i never have to do them since im an EMT and technically only Paramedics are allowed to do reports.
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Why? Is that written in your local protocols?

There's been times that during a cardiac arrest resuscitation with limited manpower, I had my EMT driver call in the report stating PT age, downtime, initial/current rhythm, ETA, and "following ACLS protocols"...
 
feldy said:
Although i never have to do them since im an EMT and technically only Paramedics are allowed to do reports.
Click to expand...

When I worked in the Boston area, I still gave entry notes as an EMT on an EMT ambulance and no one told me to stop.
 
I write down the info for my radio reports on a note pad and read from there. If I dont, I get flubbed up and do the "uh uh uh"
 
Sasha said:
I write down the info for my radio reports on a note pad and read from there. If I dont, I get flubbed up and do the "uh uh uh"
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This.

It also helps me to view the radio report, the narrative, and the turnover as the same exact thing.
 
adamjh3 said:
It also helps me to view the radio report, the narrative, and the turnover as the same exact thing.
Click to expand...

But they're not the same thing. The radio report is just a quick heads up, patient condition, what you're doing, and ETA. The handover report, to the RN at bedside, should be significantly more detailed. The narrative, your complete record of the entire patient contact, should be far more detailed still.
 
n7lxi said:
But they're not the same thing. The radio report is just a quick heads up, patient condition, what you're doing, and ETA. The handover report, to the RN at bedside, should be significantly more detailed. The narrative, your complete record of the entire patient contact, should be far more detailed still.
Click to expand...

Depends on the area I guess.around here there's no trust between prehospital personnel and the hospital. Thus every patient going into the ER gets a detailed radio report.

Also, why should your turn over be any less detailed than your narrative?
 
adamjh3 said:
Also, why should your turn over be any less detailed than your narrative?
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narratives need to be written so that anyone off the street can read it and comprehend it without any possibility for confusion/question; IE: "patient was secured to stretcher with all three belts tightened securely and shoulder straps in place"

nurses generally have a little more common sense in that aspect...
 
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