Paramedic Patient Care Reports PitFalls
In this episode of “First Responders and Coffee,” Jason Jolson and KJ delve into the nuances of proper Prehospital Care Report (PCR) writing. Documenting patient cases accurately and effectively is crucial for medical Paramedics. In this discussion, they identify common pitfalls that paramedics should avoid to improve their PCR writing skills.
Incomplete or Missing Information Completing the PCR with thorough and accurate information is essential. This includes details from assessments that might not be covered by mandatory checkboxes in electronic PCRs (ePCRs). Patient demographics, which serve billing purposes and patient identification, should never be overlooked.
Unclear Language and Abbreviations Using clear language is paramount. While medical abbreviations can be employed, they should be standardized and not lead to ambiguity. Texting lingo and abbreviations unrelated to the medical field, such as those used in casual texting, must be avoided at all costs.
Lack of Objectivity Objectivity in PCR writing is crucial. Responders must stick to facts and information they have directly observed or gathered from patients. Speculation, assumptions, or personal beliefs should never make their way into PCR narratives.
Failure to Document Changes or Interventions PCR documentation should include any changes observed in the patient’s condition, especially after interventions are administered. This ensures a complete record of the patient’s journey and the effectiveness of treatments provided.
Inconsistent or Inaccurate Information Careful attention to detail is crucial to avoid errors that can arise from spelling mistakes, jumbled words, or contradictory statements. Hospitals and medical professionals may have their own abbreviations or acronyms, so consistency is key.
Insufficient Detail PCR narratives should contain enough information to prevent misinterpretations. Specific details about locations, interventions, medications, and their timing need to be documented accurately for a comprehensive patient record.
Failure to Include Negatives Including information about what was ruled out is essential to provide a complete picture of the patient’s condition. Negatives can be just as important as positives in determining the course of action and decision-making.
Omission of Handover Details For transfers between medical facilities, proper handover details must be documented. This ensures seamless continuation of patient care and prevents misunderstandings or errors during transitions.
Delayed or Incomplete Documentation Completing the PCR as soon as possible after the call is ideal. Fresh recollections and prompt documentation enhance accuracy. In complex cases, taking a moment to decompress before writing can prevent overlooking crucial details.
Writing effective PCRs requires attention to detail, objectivity, and clear communication. By avoiding these common pitfalls, responders can provide accurate, complete, and useful documentation that contributes to quality patient care and professional accountability.