Post Examples of PCR Narratives

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My apologies, I didn't realize it was a non-standard abbreviation. It is my department's set abbreviation for a dialysis center in our reporting.
 
gotcha. my transport charts are really similar to my 911. and since i didn't realize it was dialysis....lemme fix it. eta there ya go....

Ambulance XYZ dispatched by [company communication (as opposed to county dispatch)] to SNF for an interfacility transport to DIA, response at a non-emergent rate. Additional information relayed a [76 yof going for dialysis treatment], pt on O2 @ xlpm/not on O2; pick up time 1330.
ATF 76 yof laying supine in her bed in her room, with head slightly elevated; pt sleeping. Pt on 2lpm O2 via N/C.
HPI Pt states she is going to dialysis for her normal treatment. Pt offers no complaints to EMS and denies any pain or other symptoms.
PE - HEENT: pt CAOx4 (person, place, time, event), PEARRL, no noted bruising, swelling, or other signs of injury or trauma to face/head; NECK/SPINE: no noted tenderness, deformities, or pain on palpation; CHEST: lungs C&EtAx4pt anterior; ABD: SNTx4q, no noted distention. EXTREMITIES: pt MAEx4 with purpose and upon command, pulse/sensory function present. Skin is warm, with good color.
O/A pt was found as above. Pt was moved to litter with assistance from staff; pt placed on litter in near-supine position with head slightly elevated and secured with litter straps x3. Pt was kept on 2lpm O2 via N/C per her current flow rate throughout transport. Pt was transferred to the ambulance, secured in the ambulance, and was transported to DIA @non-emergent rate. No changes in pt condition during transport; vitals are as noted in flow chart. O/A @ DIA pt was placed in treatment chair, care was transferred to Jane, RN, with report given; Ambulance XYZ returned available.

EMT, #123456

~OR~
PE: pt refused physical exam, allowed vitals; visual assessment reveals Pt airway is open, and self maintained, respirations are without extra effort and good rate, skin color is good with no noted cyanosis. Pt MAEx3 with purpose and upon command; pt LL is amputated above the knee. Pt is A&Ox4 (person, place, time, event) and answers all questions appropriately.
 
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As of JAN 1 of this year, my volly company forbid the usage of abbreviations. We believe this to be because the guy who is in charge of QA/QI doesn't know the abbreviations, and states that since he can't read the PCR, we need to change our system.

For my job, I'm okay with that. We use ePCRs there, so I basically have unlimited room for my narrative, so I have no problem writing a lot longhand.

My volly department, though, is still on paper PCRs. Takes me forever to write everything out longhand. -_- The plus side is, like the guy says, we can never be misunderstood.


Anyone else here use ePCRs? What do you think of them?
 
If you're using common abbreviations and the QA/QI guy doesn't understand them, then I have serious questions about how good of a job the QA/QI person is doing anyways.
 
JPINFV said:
If you're using common abbreviations and the QA/QI guy doesn't understand them, then I have serious questions about how good of a job the QA/QI person is doing anyways.
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You have no idea. Believe me when I say, everyone will breathe a sigh of relief when he is gone. He's a giant posterboard of what is wrong with EMS, especially on the volunteer-side.

And more unfortunate, he runs the EMS at my volly company, which not only provides service to our area, but ALS to 5 other agencies (abour 1/3 of our county), and he teaches our EMT B/I/CC classes. (Enter the reason why our Basics barely do clinicals, and our Intermediates don't even do tubes/lines prior to taking NYS exam.)
 
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we've uswed emstat @ all the compnies i've worked for....nit a huge fan but i've seen worse....
 
eynonqrs said:
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
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I think this is great short and simple.
 
wyoskibum said:
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
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I like this method
 
Closed for 11 year old bump
 
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