PCR Narrative

bradpop14

Forum Ride Along
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Hey fellow EMS personnel! New to the forum and EMS in general. I recently was hired on through an IFT company here in LA County.

Part of my field training was the proper way to write a narrative. While on my first shift I realized how hard it is for me to lay out an organized, precise, and short narrative for everything that was seen and performed.

Is there anyone here that has some advice? Maybe a format they use and trust? Or even a website that shows abbreviations. Please share!
 

NJEMT95

Forum Lieutenant
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There have been many threads discussing this - try doing a few searches and you'll find plenty of suggestions and examples.
 

DrankTheKoolaid

Forum Deputy Chief
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What were you paged to, what did you see and were told at the scene, your exam, your treatment and any changes, arrived at what hospital and who did you give your report to. No further patient contact (your cert number)
 
OP
bradpop14

bradpop14

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Sorry if this is a redundant post. I searched around for PCR and couldn't find something.
DrankTheKoolaid do you have any reference for abbreviations?
 
OP
bradpop14

bradpop14

Forum Ride Along
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NJEMT95 I just wasn't looking hard enough. Found what I needed!!
If a mod could close this, that would be appreciated
 

TacomaGirl

Forum Probie
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Everyone charts differently and seems every supervisor has their personal view of what is good and what is not.

I have a couple of samples saved on the tough book and pretty much follow the same rhyme and rhythm with each call.

Why you were dispatched, Pt contact, subjective and objective head-to-toe, interventions, what you did in ambulance, where you took pt, who you gave report and always end with "all times approximate".

Good luck
 

wanderingmedic

RN, Paramedic
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Don't over think it. Explain what you did and why. Use the narrative to cover your bottom, and tell the story of what happened. The electronic PCR's do a great job of gathering raw data (vitals, times, interventions, etc), but the narrative is your chance to explain your interpretation of that data and justify your interventions (if any). If the PCR is ever reviewed by your Medical Director, or you get sued, the narrative should connect your objective and subjective assessment findings to your interventions, and show your train of thought. It, coupled with the rest of your PCR, should be thorough enough for someone who was not there to fully understand what happened.
 

erscribe

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Remain objective and state the facts in your charting.

For example:
inappropriate - patient appears intoxicated.

appropriate - patient ataxic. acetone odor on breath. admits to drinking several beverages of alcohol within the past 3 hours.
 

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