The example above is a paper PCR, in Georgia a thing of the past. In 2012, Georgia PCR’s were completely digital dragging the EMS community of Georgia into the computer age. From the written PCR above, you can see how poor handwriting could make this document extremely hard to read.

Anatomy of a PCR

Whether the PCR is paper or digital, the data being obtained is pretty much the same. The call address, medic crew, and dispatching times will usually be the first information provided on a PCR. The patient’s name and address is usually found at the of the report as well.

Next is the dreaded narrative. EMS personnel often struggle with their ability to write a reasonable narrative. Georgiaemsacademy students fair much better when writing PCR narratives because they understand patient assessment supremely better than other EMS personnel. Using the framework of patient assessment, one could understand the details the narrative was trying to capture. Narratives are generally written in the spoken word with very little medical terminology. Radio codes and nicknames for various types of patient situations should never be used when writing the narrative of the PCR. The use of abbreviations is acceptable so long as they are agreed upon (there is generally a list of acceptable abbreviations). Being able to quote the patient or bystander make the document much more readable. It is never necessary to type in blood pressures or other vital signs into the narrative. Vital signs, history, medications, and allergies are typically considered data and will be selected from a drop down list.

A patient care report should be, in one word, accurate. Document accuracy depends on all information provided, both narrative and checkbox, being precise and comprehensive.  All checkbox sections of a document must show that the medics attended to them, even if a given section was unused on a call.  Be sure to that all medical terms, abbreviations, and acronyms are properly used and correctly spelled.  If you are using a paper patient care report, be sure that the handwriting is legible (means that handwriting, especially in the narrative portion of the document, can be read by others without difficulty).  Checkbox marking should be clear and consistent from the top page of the document to all underlying pages.  The documentation should be submitted in a timely manner (timeliness often depends upon where you work).  Documentation should be completed ideally before the EMT or Paramedic handles tasks subsequent to the patient interaction (like going to another call).  Since the patient care report is a legal document, the document should be unaltered (this means that after the report was submitted, no other additions or changes are to be done).  While writing the document, should the EMT or Paramedic make an error, a single line should be drawn through the error, initialed, and dated.  Should alterations to a document be required after the document has been submitted, follow the following guidelines:

• Write revisions to documents on separate report forms
• Note the purpose of the revision, and why the information did not appear on the original document
• Note the date and time
• Revisions should be made by the original author of a document
• When the need for revision is realized, it should be done as soon as possible
• Acceptable methods of corrections include rewriting the narrative on another patient care report and attaching it to the original.  This can be accomplished with an addendum or similar form. 
• Deletions and additions are accomplished on a new form.
• If you need more room than what the PCR will allow for, utilize a supplemental or equivalent form and attach it to the original.  

The document should have a professional quality about it.; therefore you should refrain from including non-professional/ extraneous information.  Non-professional/ extraneous information is more a matter of opinion than anything else.  Always avoid the following:

• Jargon – Specifically, jargon that nobody else could possibly know.  EMS or medical terms are acceptable while ‘frequent flyer’ or ‘crispy critter’ would be considered jargon.
• Slang – Unless you are quoting a patient, ‘all crunked up’ would probably be an example of slang.
• Bias – Bias means that your documentation reflects a narrower point of view than is necessary to convey the message.  
• Libel/ slander – Accusatory or derogatory statements that have the intent of defaming the object of your writing.  
• Irrelevant opinion/ impression – Be like Dragnet, “…just the facts, ma’am…”

Keep It Clean With SOAP

The standard format for all medical communication is SOAP. SOAP stands for:

Subjective + Objective + Assessment = Treatment

A good way to look at a narrative is to analyze what the EMS crew perceived to be the patients problem based on their assessment. What the patient told them (subjective) combined with what they saw or measured (objective) should allow the EMS provider formulate an an opinion. The treatment should be commensurate with the perceived problem. Using such a philosophy, the interventions of the EMS crew can be judged as adequate or not.