PCR's & prehospital documentation

[InkaHootz]

Looking for resources to provide my agency with quality standards of documentation.

What do you do to ensure a quality written report? Do you have any special "quirks" to your method or that you include in your end product?

What software or "program" do you use?

Do you stay and wait at the hospital? Return to base/the unit and write it? Do you print it off? Fax it? Email it?


This Thread = Everything and anything documentation.

 

[Shishkabob]

What do I personally do? Remind myself that this document will be the only thing there is to remind me of a call in 5 years when it goes to court.


State law requires SOMETHING must be left my EMS at the hospital with the patient, either PCR or some patient info sheet. I typically get the whole PCR done while at the hospital without MUCH delay, however it can be done later, too. As long as it's done by the time I leave, it's all good.




My agencies have used ePCRs, and programmed them so that all necessary info is included before it can be closed and finalized.

My first agency used the Zoll ePCR. My current uses the Siren ePCR.

 

[Epi-do]

My current uses the Siren ePCR.

Ugh!! I HATE Siren!!!! Fortunately, in about a week and a half, we are switching to ESO. We had the training on it this week, and I have had the opportunity to play around with it some and I like it tons better. It just seems a lot easier to use, and has some nice features that we didn't have with Siren.

 

[Shishkabob]

Ugh!! I HATE Siren!!!! Fortunately, in about a week and a half, we are switching to ESO. We had the training on it this week, and I have had the opportunity to play around with it some and I like it tons better. It just seems a lot easier to use, and has some nice features that we didn't have with Siren.

I've only been using Siren for a week, and I too hate it. I prefer Zoll to it .

Though apparently they're shopping around for a new ePCR program and should make a decision in about 6+ months.

 

[JPINFV]

Everything and anything about documentation?

http://emtmedicalstudent.wordpress.com/2011/01/20/ems-documentation-introducing-pre-soaped/

 

[NomadicMedic]

Luckily, or unluckily, depending on how you look at it... we have a statewide ePCR system that is available form any computer with a web connection. It's nice because it tracks EVERYTHING, it's easy to use and it's available everywhere.

We don't use the typical SOAP or CHART method, instead the only real text blocks we write are a "Chief complaint/HPI", a "general impression" and a narrative that will include explinations for interventions in the event timeline and the PT's condition at turnover.

I've used both Zoll's ePCR (which sucked) and Emergency reporting, which sucked less. The Delaware EDIN system is far from perfect, but very easy and suitable for what we do. The word on the street is that the "new" ePCR system for the state will be up soon. Not holding my breath.


there's a nice PDF about how our system works HERE

***EMS Data Information Network (EDIN)

The EDIN system collects EMS report data electronically on a real-time basis and provides administrators with a powerful resource management and research tool. The EDIN system collects, at minimum, over 130 data points covering the demographic assessment and treatment phases of an EMS incident. The EDIN system has been online since January 1, 2000. Since it's inception, over 250,000 records have been entered into the system. Currently, all of the Advanced Life Support agencies in Delaware are using the system on a full-time basis. Of the 58 volunteer Basic Life Support agencies, almost all are using the system on either a full time or partial basis.

 

[DesertMedic66]

We use the MEDs program on the panisonic toughbooks.

The program if far from perfect and is always changing so you never really get used to it before it updates. The only information we have to actually type in is for our narrative. Everything else we just have to click on.

 

[Epi-do]

We are currently using toughbooks as well. However, they are kicking around the idea of getting iPads as they need replaced, since the new software we are going to is supported by them, and we were just told the iPads are actually more cost effective than the toughbooks.

 

[DesertMedic66]

We are currently using toughbooks as well. However, they are kicking around the idea of getting iPads as they need replaced, since the new software we are going to is supported by them, and we were just told the iPads are actually more cost effective than the toughbooks.

My college is going to be getting 8 IPads for the EMT class so students can learn how to document using ePCRs.

As for real world use I don't see them being used for my service at least. To be frank our gear gets pretty abused. And well iPods, IPhones, and IPads dont have the best track record for damage from a simple small drop.

 

[NomadicMedic]

... And well iPods, IPhones, and IPads dont have the best track record for damage from a simple small drop.

They do when you put them in an otterbox. My iPhone has survived several drops out of the back of an ambulance on to concrete none the worse for wear.

 

[JBFab]

We use WARDS, an acronym for the Wisconsin Ambulance Run Data System. It isn't too bad, one nice feature is that you can auto-fill the narrative based on the info entered using several different formats (like SOAP and CHART). You can also add your own comments.

This quote from Linuss:
What do I personally do? Remind myself that this document will be the only thing there is to remind me of a call in 5 years when it goes to court.


Is VERY sound advice.

 

[Tigger]

Understand that if you're working IFT and you see the same patients frequently that this does not give you license to skimp on the PCR. Write a complete report for every call, without exception. You have no control over when something will deviate from normal, may as well just take the extra two minutes and not cut corners.