Post Examples of PCR Narratives

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AnthonyM83

AnthonyM83

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I know different philosophies and formats for patient care report narratives, but looking to see various examples of them. How those formats and philosophies actually play out into actual narratives. Also, notes on whether there are separate sections for information left out (GCS, Vitals, Hx, etc).

Also, looking to read real ones that are actually used (versus "perfect" ones that would be rated an A+). Just seeing how many pertinent positives, negatives people might use (what's a good amount versus overkill).

Just throw out some examples for common things like : Chest Pain, Shortness of Breath, Seizure, Abdominal Pain, Minor Injuries, Major Traumas, Cardiac Arrest, "Sick" calls...whatever you like
 
I work for/with a department that requests it's crew chiefs write very standardized PCRs. The calls the department encounters tend to be minor medicals, etc, and often refusals, but can range widely, yet we still use the same algorithm. A minor trauma (refusal) would look something like this

(SC) OAF 24 yom, CA+Ox4, seated on stairs, ICO friends. (CC) Ankle Pain (HPI) Pt. states he was walking down stairs when he fell down "3" steps, and "twisted" ankle, 5 min PTOA, then walked to scene (approx 50'). Pt denies falling, hitting head, prior weakness, states prior "twisting" ~5 years ago. -LOC, -H/N/B pain, -DZI, -CP, -DB, -SOB, -ABD Pain, -N/V/D, +CSMx4, -DCAPBTS, +L. Pt. denies all other pain or abnormality. (PE) Vitals as noted. Pt c/o 4/10 "sharp" pain to L lateral ankle, increasing upon palp, pressure, decreasing with cold compress. pt able to ambulance w/o assistance, but with pain. + distal CSMs, + ROM. Skin P/W/D, Pupils PEARL, LS clr=bilat. Rest of Secondary survey unremarkable. (TX) VS assessed, PE performed, ice pack applied, with some relief. Pt. advised of treatment and transport options. Pt expressed intent to refuse care at this time, call clinic, receive transportation from friends, and receive care "ASAP". (TP) Pt. refusal signed and witnessed (by XX). Pt left ICO friends, with instructions to follow up at clinic ASAP and call if further care needed.
 
Is it sad that I can understand and read that entire narrative without a moments pause?


I typically do a mixture of SOAP and CHART... trust me, it makes more sense when it's written out. Sadly I don't have one near by, and seeing as it's after midnight, my imagination is non-existent. Just know that it's awesome.
 
Given a blank page, I tend to use a variation of SOAP, called: SOAPIE or SOAPIER... depending upon if I have to revise the plan...

If the report isn't completely blank, I modify my charting style to prevent writing stuff down twice. When I do this, I make certain that everything I do has a time associated with it so that a timeline of events could be recreated without much, if any, effort.
 
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Linuss said:
Is it sad that I can understand and read that entire narrative without a moments pause?


I typically do a mixture of SOAP and CHART... trust me, it makes more sense when it's written out. Sadly I don't have one near by, and seeing as it's after midnight, my imagination is non-existent. Just know that it's awesome.
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Not sad unless it is sad that I can too........

I usually use a mix of SOAP(E) and a sequential narrative. It turns out more like SOPEA I don't like using abbreviations much, so mine can turn more like a story than a report.

eg:

S/O: Unit dispatched to 123 N. Random St. for a 68 yom sick u/k, hx DM. OAF pt sitting in easy chair, decreased response. RP states pt "was here when I went to bed and was in the same spot when I woke up". Pt has hx DM and is not insulin dependant, hx of low BGL. RP states LOI probably 1800 on (date).

I/A: A: Patent. B: Shallow non-labored. C: Weak Radial. Good cap-refil. C-spine: No MOI. Pupils: PEARL. LOC: Pt responds to loud verbal. Bleeding: None. Skin: Cool, pale, moist. HEENT: 0 abnormalities noted. Chest: Equal + bi lat expansion w/ resp. Lungs: Clear equal and bi-lat upper and lower, front. Heart: ST. Abd/pelvis: 0 abnormalities noted. Back: Not examined. Ext: good movement X4. Edema in lower ext. Neuro: Pt confused and combative. Hx: DM. RP states no other PPMHx. RP states NKA/NKDA. Meds: See attached.

P: I/A, vitals (see below), 3 lead, BGL (34), IV 16 ga L AC, 25 ml D50% SIVP, + 5 min BGL (50), 25 ml D50% SIVP, +5 min BGL (95), O/A.

O/A: Pt's LOC improved to Alert. Pt became A&Ox4, states LOI approx 1830 on (date) got distracted watching TV and forgot to check BGL later in PM. Pt denies any other problems. Pt refused transport. Advised to eat something as soon as possible. Pt signed refusal, withnessed by xxx and xxx. Pt left ICO wife.

~~~~~~~~~~~

Ok, so that is a made up scenario, so I'm sure I left some things out.
 
I like to use a form of the CHART method called LCHARTI:

(L)ocation
(C)hief complaint
(H)istory of Present Illness/Injury
(A)ssessment
(R)x - prescription/treatment
(T)ransport
(I)mpression

(Location): Medic 1 responded to above location on a report of a 62 y.o. male c/o of chest pain. Upon arrival, pt presented sitting in a chair attended by first responder. Pt appeared pale and having difficulty breathing.

(C/C): "I have pain in my chest"

(HxPI): Pt had a sudden onset of substernal chest pain ~1 hour prior. PMHx of AMI 2 years prior with cardiac catherization with stints placed, COPD, 20+ year smoker, hypercholestermia.

(Assessment): Pt AOX4, GCS=15. Skin pale, cool, & diaphoretic. No JVD noted. Pt c/o chest pain/pressure 8/10. Lung sound clear += in all fields. Remainder of exam was unremarkable. No peripheral edema noted. Pt also c/o nausea. Last oral intake was breakfast at 08:00 this am.

(Rx): vitals, oxygen, monitor, 324 mg ASA PO, I.V. established 18 g (R) AC @TKO rate, 12-Lead aquired showing showing ST elevation in Leads II & III. NTG sublingual with decrease of pain to 4/10, transport.

(Transport): Pt transferred to stairchair and transported down stairs. Pt transferred to gurney and then ambulance. Report to medical control, no instructions recieved. Pt transported to hospital without incident. Pt condition improved.

(Impression): chest pain r/o AMI
 
Here ya go... Standard SOAP.

Medic 19 dispatched priority @ 1854 to a private residence for an 85 year old male experiencing SOB and CP. PT states he was attempting to drain the water from his basement following his sump pump malfunctioning. As he became more anxious, he began having increased difficulty breathing and SOB, accompanied with sub sternal CP. PT states he took one 0.4mg NTG SL 10 minutes prior to our arrival with full relief. PT has a history of NIDDM, a MI over 10 years ago, a Coronary Bypass 6 years ago, HTN, GERD and anxiety. Pts medications include Simvastatin, Glipizide, Losartan, Zantac and NTG. PT has a sensitivity to Morphine Sulfate and is allergic to shellfish. PT has been complaint with his medication, according to his wife. PTs last meal was a chicken breast and rice.

Upon our arrival PT was found sitting on the couch, in a high state of anxiety due to his flooded basement. PT was CAOx3, GCS 15, with no signs of trauma noted. He was breathing rapidly and complaining of SOB and tingling around his lips and his fingers. He stated he had some “chest tightness earlier, but it was gone now” following his NTG administration. PT skin was pink,warm and dry. BASELINE VITALS: HR 92, BP: 150/80, RESPIR 26, SpO2 98% on RA. TEMP: 98.4. BGL: 112 12 LEAD: NSR at a rate of 88, with no ST elevation noted. HEENT: Pupils PERRL, no signs of trauma noted. No TD or JVD noted. CHEST: Lung sounds: Clear and equal bilaterally. ABD: Soft and non tender. PELVIS: Intact. EXTREM: PT had good PMS in all extremities.

Pt transported to Hospital ED R/O anxiety/hyperventilation.

BSI, PT contact and interview. Vitals as above. PT placed on monitor and 12 lead obtained within 10 minutes of our arrival. (Attached). PT placed on 3 lpm of O2 via NC with ETCO2. PT was able to stand and pivot to stretcher and was secured with safety straps. Pt was moved to ambulance for detailed exam which was unremarkable. IV access was obtained in L AC 18G with 1000ml of NS set at TKO rate. During transport, PT was coached on slowing his breathing and would slow for a short time and then immediately return to his previous tachynpea. En route VITALS: HR: 88, BP: 132/70, RESPIR: 24 and non labored. SpO2: 100 on 3 lpm via NC. ETCO2: 27. Lungs remained clear and equal bilaterally. PT tolerated transport well and stated that he continued to be pain free. Telephone report to ED was made to notify staff of impending arrival. Upon arrival at ED, PT was moved to room 2 via 3 person draw sheet lift. Report given to John Doe, RN. Prior to leaving the ED, I notified the PT that the crew from Engine 18 had repaired his sump pump and his basement was being pumped out. He seemed to relax somewhat after hearing that news. Transport occurred without incident or complication and Medic 19 returned to service at 1957.
 
n7lxi said:
Here ya go... Standard SOAP.

Medic 19 dispatched priority @ 1854 to a private residence for an 85 year old male experiencing SOB and CP. PT states he was attempting to drain the water from his basement following his sump pump malfunctioning. As he became more anxious, he began having increased difficulty breathing and SOB, accompanied with sub sternal CP. PT states he took one 0.4mg NTG SL 10 minutes prior to our arrival with full relief. PT has a history of NIDDM, a MI over 10 years ago, a Coronary Bypass 6 years ago, HTN, GERD and anxiety. Pts medications include Simvastatin, Glipizide, Losartan, Zantac and NTG. PT has a sensitivity to Morphine Sulfate and is allergic to shellfish. PT has been complaint with his medication, according to his wife. PTs last meal was a chicken breast and rice.

Upon our arrival PT was found sitting on the couch, in a high state of anxiety due to his flooded basement. PT was CAOx3, GCS 15, with no signs of trauma noted. He was breathing rapidly and complaining of SOB and tingling around his lips and his fingers. He stated he had some “chest tightness earlier, but it was gone now” following his NTG administration. PT skin was pink,warm and dry. BASELINE VITALS: HR 92, BP: 150/80, RESPIR 26, SpO2 98% on RA. TEMP: 98.4. BGL: 112 12 LEAD: NSR at a rate of 88, with no ST elevation noted. HEENT: Pupils PERRL, no signs of trauma noted. No TD or JVD noted. CHEST: Lung sounds: Clear and equal bilaterally. ABD: Soft and non tender. PELVIS: Intact. EXTREM: PT had good PMS in all extremities.

Pt transported to Hospital ED R/O anxiety/hyperventilation.

BSI, PT contact and interview. Vitals as above. PT placed on monitor and 12 lead obtained within 10 minutes of our arrival. (Attached). PT placed on 3 lpm of O2 via NC with ETCO2. PT was able to stand and pivot to stretcher and was secured with safety straps. Pt was moved to ambulance for detailed exam which was unremarkable. IV access was obtained in L AC 18G with 1000ml of NS set at TKO rate. During transport, PT was coached on slowing his breathing and would slow for a short time and then immediately return to his previous tachynpea. En route VITALS: HR: 88, BP: 132/70, RESPIR: 24 and non labored. SpO2: 100 on 3 lpm via NC. ETCO2: 27. Lungs remained clear and equal bilaterally. PT tolerated transport well and stated that he continued to be pain free. Telephone report to ED was made to notify staff of impending arrival. Upon arrival at ED, PT was moved to room 2 via 3 person draw sheet lift. Report given to John Doe, RN. Prior to leaving the ED, I notified the PT that the crew from Engine 18 had repaired his sump pump and his basement was being pumped out. He seemed to relax somewhat after hearing that news. Transport occurred without incident or complication and Medic 19 returned to service at 1957.
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That is a fine report, I need to get better at the one's I do for clinicals.
 
I tend to just write things out as they happen in a strictly chronological order.

An example of a fairly typical report for me:

Dispatched priority 2 to a residence for a patient experiencing difficulty in breathing. Upon arrival to scene, a 90 year old patient in care of family is found positioned semi-Fowler's in bed. Patient appears lethargic and is breathing from abdomen. Patient does not respond to questions, but crew is informed by family that patient is deaf. Per family, the patient has been "sick" today and after consulting with the patient's doctor, they wish the patient to be transported to HospitalA for treatment. Family confirms patient has had fever for past 12 hours and has become increasingly lethargic throughout the day. Rx, Hx, and allergies noted in appropriate tables. Vital signs taken as noted. BP: 90/40, HR: 100, RR:36 and shallow, BGL: 80, SpO2: 82% on RA, skin feels hot and moist, lung sounds CTA. Cyanosis is noted in lips and nail beds. Patient is placed on NRB @ 10Lpm, carried to stretcher by EMTx2, seated in high Fowler's position, and secured without incident. Patient moved into ambulance and requested hospital contacted via radio and informed of 20-25 minute ETA. HospitalA directs diversion to closest facility. Crew begins transport of patient without lights and sirens. En route, patient monitored and vital signs repeated. BP drop to 60/30 noted and patient is now responsive only to painful stimuli. Transport upgraded to lights and sirens. Patient leaned back into lower Fowler's position and feet elevated. Upon arrival to facility, there are no further changes to patient condition. Patient is placed in ED bed with staff present and without incident. Oral and written report given and care turned over to hospital staff. END


I really only use abbreviations and shorthand rarely.
 
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Dispatched to the above location for a pt "with an elevated temp". Arrived on scene to find a male pt lying in bed, CAO X 3 with a GCS of 15. Pt stated that he was not feeling well X 2 days and has been running a temp. Pt stated that he did take Tylenol and still the temp did not go down. Assessed pt and found skin to be very warm and dry, BP 150/80, pulse of 110 and regular. Lungs were clear in all fields. -dizziness -vomiting. Pt has eaten this morning and has been able to take normal fluid intake. Pulse ox was 90% on room air. Temp was 101.3. Placed two ice packs under the arm pits to control temp. Placed pt on 6LPM via simple face mask. Pulse ox then rose to 97-98%, Pt has no pmhx, -allergies. - meds. Called report to hospital via med radio, no orders given. Arrived at hospital and transfered care to ER staff.

Initals and EMT #
Company
 
Here is a scanned copy of a really interesting job I had a while ago

 
MrBrown said:
Here is a scanned copy of a really interesting job I had a while ago

Click to expand...

20 of morphine and 20 of ketamine? You can take care of me anytime. :)
 
MrBrown said:
Yeah but you'd be so wasted you would miss my charming rabior like whit and tact B)
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just make sure not to step on any of the spiders :)
 
here's a report i did for medic school....pretty much used the same format for all my calls, BLS/ALS/transport/etc...

DATE Medic X-X-X ALS, trauma alert

RADIO/COMMAND REPORT
LGH Med Command, this is paramedic student on Medic X-X-X. Enroute to you with an 82, 8-2year old female who got dizzy and fell down a full flight of approximately 15 steps sometime between 0400 and sunrise today, unknown loss of consciousness; got up and was found sitting in a chair in her kitchen by neighbors. Pt is alert and oriented x2; she has a lac on the R side of her head, no active bleeding, and a large bruise on her upper R chest. Pt is complaining of R shoulder pain and pain all over; denies any difficulty breathing. Pt does take one baby ASA every day, no other blood thinners. BP is 183/97 , P86, R18, bG 188. ETA is 10 minutes.

WRITTEN REPORT
DISPATCH: class 1 response to the pts residence for an injured person; Medic X-X-X responded immediately. Additional information from X911 dispatchX relayed an 82 y/o/f who fell down the steps.
ATF: Neighbors met EMS and led EMS to the pt; pt found sitting in a chair in her kitchen with dried blood matted on the R side of her head.

HPI: Sometime b/t 0400 when pt awoke and sunrise, pt was walking up the steps, and was near the top (~ 15 steps up) when she got dizzy and fell backwards down the steps; pt does not think she was knocked out but states she did not get up right away. Pt did get up and walked to a chair in her kitchen (about 10 feet), where she was found by neighbors shortly before noon. Pt c/o R shoulder pain and states she also has 'pain all over'; pt denies any nausea, respiratory difficulty, lightheadedness, or any other symptoms.

PE: HEENT: pt is conscious, A&Ox2 (person, event), PEARRL @ 3mm, airway is patent and self-maintained; the R side of the pts head was covered in dried, matted, blood; no active bleeding; pt is slightly slurring her speech, no noted facial droop. NECK/BACK: no noted deformities, tenderness, or crepitus to palpation; CHEST: rise and fall equal, L/S C&EtA x6pt anterior, (+) fist-sized bruise on the UR chest; pts R shoulder appears deformed anteriorly, no noted crepitus. ABD: SNT, no noted distention or palpable masses present. PELVIS: intact with no noted instability or crepitus. EXTREMITIES: pt MAEWx4 with purpose and upon command, P/M/S funtion present x4 extremities; grips, wiggles, and pushes are equal with no noted weakness. Central and peripheral skins are equal in color, temperature, and moisture, with no noted cyanosis, pallor, or diaphoresis.

RX: ALS assessment, full spinal immobilization, EKG - Sinus Rhythm w/ occasional PACs/PJCs, O2 - 4 lpm via N/C, IV - 18g back L AC 1000cc NSS KVO, IV - 18g R AC - unsuccessful attempt, IV - 18g back R hand 1000cc LR KVO, bG - 188 mg/dL, vitals, monitor, CMC @ LGH for trauma report - MC# (Dr. R____).

RE-ASSESSMENT: pt c/o feeling sleepy, no other changes noted.


FLOW CHART
1220 initial vitals - P76 slightly irregular, R18 N/L, 96% SaO2 RA
1224 EKG
1228 vitals - P88 R18 96%
1233 vitals - 166/081 P80 R20
1238 vitals - 153/091 P82 R20
1245 vitals - 184/097 P80 R18
1250 vitals - 186/085 P77 R18
1250 CMC - MCDr@LGH, trauma report
1255 vitals - 175/094 P82 R20
1259 vitals - 185/087 P80 R18


A: nkda
M: prilosec, actonel, baby ASA, prevachol, effexor, fluoxetine
P: HTN, heart arrhythmia

my name, emt number, Paramedic student.
medics name, Paramedic preceptor
 
Does anyone know of a good website or book that will help with abbreviations? I know the basics and I have small little handbook but it seems that there are way more abbreviations than what we learned in class. I'd like to really know them well before I go on any interviews.
 
Each system I've ever worked in had their own approved abbreviations and symbols. You might find some that are commonly used, but be aware that the system you work in may assign that abbreviation a different meaning.
 
I am going to bump this old thread with a new request. I am looking to see what a basic IFT PCR looks like from others. Let's say....SNF to DIA. Thanks!
 
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