1. Chapter 4 Documentation Advance Preparation
Bring copies of paper Prehospital Care Reports (PCRs) or an electronic documentation format to demonstrate.
Invite the medical director or an emergency nurse to discuss how they use information from PCRs left in their department.
Photocopy the PCR format you want students to use in class and any handouts from the Instructor Resource Package.
Write a fictitious PCR prior to class and photocopy it as an example for students.
Enlist an assistant instructor to role play a refusal of treatment scenario with you to illustrate the process for the class.
Prehospital Emergency Care, Ninth Edition
Joseph J. Mistovich • Keith J. Karren
Copyright ©2010 by Pearson Education, Inc.
All rights reserved. 1

2. Objectives Define key terms introduced in this chapter.
Describe each of the following purposes served by the prehospital care report (PCR) (slides 12-22):
Continuity of patient care
Administrative uses
Legal document
Education and research
Evaluation and continuous quality improvement (CQI)
Describe characteristics, including advantages and disadvantages, of both paper and computer-based (electronic) PCR formats (slides 23-24).
The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

3. Objectives
Explain the purposes of the U.S. Department of Transportation (DOT) minimum data set for PCRs (slide 26).
List the elements of the DOT minimum data set for PCRs (slides 26-27).
Describe the purpose and contents of each of the following sections of a PCR (slides 28-37):
Administrative data
Patient demographics and other patient data
Vital signs
Narrative
Treatment
The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

4. Objectives
Give examples of each of the following types of PCR narrative information (slides 34-35):
Chief complaint
Pertinent history
Subjective information
Objective information
Pertinent negatives
Use common abbreviations and medical terminology accurately in PCRs (slides 63-64).
The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

5. Objectives
Explain each of the following legal concerns with respect to the PCR (slides 38-48):
Confidentiality
Allowed distribution of the PCR or information included in it
Documenting a patient’s refusal of treatment
Falsification of the PCR
Correction of errors
The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

6. Objectives
Discuss how to handle each of the following situations with respect to the PCR (slides 48-55):
Transfer of patient care when returning to service prior to completing the PCR
Multiple-casualty incidents (MCIs)
Special reporting situations, such as infectious disease exposure and suspicion of abuse or neglect
Accurately and completely record pertinent patient and EMS call information using the SOAP, CHART, and CHEATED methods (slides 56-62).
The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

7. Topics Functions of the Prehospital Care Report
Collection of Data in Prehospital Care Reports
Legal Concerns
Special Situations
Alternative Documentation Methods
Medical Abbreviations
Planning Your Time
Plan 180 to 240 minutes for this chapter as follows:
Functions of the Prehospital Care Report (15 minutes)
Collection of Data in Prehospital Care Reports (60 minutes)
Legal Concerns (30 minutes)
Special Situations (30 minutes)
Alternative Documentation Methods (60 minutes)
Medical Abbreviations (20 minutes)
Note: The total teaching time recommended is only a guideline.

8. CASE STUDY Dispatch Case Study Discussion
The following case study is intended to challenge your students to think about how to approach an initially hostile patient, who then refuses both treatment and transport; and how to document the incident.
Present the case in a way that your students will imagine being on the call and feel challenged by the circumstances of the incident. 
If appropriate, briefly relate a personal experience you’ve had running a similar call and how you managed it.

9. Respond to 57 Vallejo Road for a vehicle versus a parked car
EMS Unit 17
Case Study Discussion, continued
You and your partner are working on EMS Unit 17 today.
You’ve been dispatched to 57 Vallejo Road. Dispatch advises there is a vehicle collision with injuries; reports that a vehicle struck a parked car and a male on scene may be injured.
Time out is 1321 hours.
Respond to 57 Vallejo Road for a vehicle versus a parked car
Time out 1321 9

10. Upon Arrival
Female party who called 911 indicates the male who struck her vehicle was slumped over wheel
States now he seems okay
As you approach a mid-30s male he states, “Great! As if I didn’t have enough trouble today, I’ve got to deal with you guys! Go away. I don’t need any help!”
Case Study Discussion, continued
You arrive in six minutes and observe four people standing around two vehicles.
You’re approached by the woman who reported the incident. She states that she was in the house, heard a crash, looked out, and saw that the man’s car had hit her parked van. She then saw the driver slumped over the wheel so she called 911 right away.
She reports that after she came out of her house, the man was ambulatory and seemed okay. She points to the man pacing around and inspecting the damage to the two vehicles.
You and your partner walk toward the man, who appears to be in his mid-30s. He looks at you and says, “Great! As if I didn’t have enough trouble today, I’ve got to deal with you guys! Go away. I don’t need any help!” 10

11. How would you proceed? Case Study Discussion, continued
Based on what you know so far, what things do you already know you will need to document on your PCR?
Any ideas about how to further approach this patient/situation?
How would you proceed?

12. Functions of the Prehospital Care Report
Teaching Time
15 minutes
Point to Emphasize
Clear and thorough documentation of EMS calls may serve more purposes than you realize—and more people may read your PCR than you realize.
Back to Topics 12

13. Continuity of Medical Care
Point to Emphasize
Information recorded about a patient allows the emergency department and other healthcare personnel to develop a more complete understanding of the patient’s condition.
Back to Objectives

14. Provides a baseline for other providers
Gives an understanding of events and reasons for the call
Talking Points
Reporting the data you obtain during your time with the patient helps ensure continuity of care throughout the patient’s need for medical attention.
When ED staff look at your description of a patient’s mental status or vital signs, they have a baseline against which patient improvement or deterioration can be measured.
When they read your account of the chief complaint and the signs and symptoms you documented, they have a clearer idea of what treatment plan they should follow for the patient.
When they see what interventions you have or have not performed, they know more clearly what measures to take themselves.
Your documentation provides details about things that hospital staff may have no access to, such as descriptions of the scene, mechanism of injury, and family information. 14

15. Administrative Uses Point to Emphasize
Administrative uses of the PCR include billing and insurance information to assist with reimbursement for the cost of care and statistics to guide EMS system decision-making.

16. Becomes part of patient record Used for billing Statistics
Talking Points
The documentation you provide typically becomes a part of the patient’s permanent hospital record.
The PCR will be used in preparing bills and in submitting records to insurance companies.
The information may be used to prepare statistics regarding the EMS system itself, such as the average response time, time on scene for critical trauma patients, or the number of cardiac arrest patients treated each year.
Discussion Question
Why is it important that EMS services bill patients and submit insurance claims? 16

17. Legal Document Point to Emphasize
You may be called to testify in a legal action months or years following a call and it will be hard to recall all the details of a call after so much time. Good documentation at the time of the call is the best guide for your testimony.
Teaching Tip
Ask several students to recall what they ate for breakfast one week ago. Use this to illustrate the difficulty in remembering things that are routine—as EMS calls will one day be for them—even after a short period of time.

18. Can be months or years later May be a defense
Talking Points
Your medical documentation will become a legal document.
Runs that seem potentially litigious in nature could lead to criminal or civil lawsuits. Such calls include those where a crime was committed and slip-and- fall incidents in public places, such as grocery stores and malls.
The EMT who wrote the report is typically called to testify in court.
Legible, accurate, and complete documentation is essential to testifying effectively and “surviving” on the stand, especially if you are being sued and are part of the defense.
Clearly document objective and pertinent subjective findings, the status of the patient upon arrival on the scene, the emergency care provided, the time the emergency care was provided, and any changes in the patient’s condition upon arrival at the medical facility.
Is legal document
May appear as a witness
Can be months or years later
May be a defense 18

19. Educational and Resource Uses
Point to Emphasize
Good documentation is essential for providing data for research, system evaluation, and continuous quality improvement. These things only help to improve our system.

20. Can look at positive or negative effects May identify training needs
Talking Points
Documentation provides data to study a whole range of issues:
Positive or negative effects of certain interventions at different stages of patient contact
How to deliver services in a more timely or cost-effective manner
Clinical care that may require additional education and training
Discussion Question
Give a specific example of how data from the PCR can be used in a research project.
Can look at positive or negative effects
May identify training needs 20

21. Evaluation and Continuous Quality Improvement

22. Documentation part of quality improvement Medical oversight
Talking Points
Reviews of documentation are an integral part of the quality improvement process.
Remedial and continuing education courses for EMTs may be based on needs revealed by call documentation.
PCRs are also used in medical oversight to determine if EMTs are adhering to protocols and the set standard of care for your area.
Critical Thinking Discussion
What are some reasons EMS documentation may not be as good as it should be?
Documentation part of quality improvement
Medical oversight 22

23. Collection of Data in Prehospital Care Reports
Teaching Time
60 minutes
Back to Topics 23

24. PCR Formats Back to Objectives Talking Points
PCRs can be paper or electronic in format. Electronic formats can be computer-, PDA-, or electronic pen-based.
Written formats may allow a more detailed patient care narrative. Electronic formats can link data, check spelling, and alert users to missing information.
Teaching Tips
Provide students with copies of PCRs used locally.
If possible, demonstrate an electronic documentation system.
Back to Objectives

25. Written Computerized Talking Points
The written report usually combines check boxes and write-on lines for vital signs and other information that can be entered briefly. It also provides areas for writing a fuller narrative account of the patient contact.
The computerized report varies in style. With some, the EMT fills in boxes (bubbles) on sheets of paper, and the report is scanned by a computer. In others, data is entered directly into a laptop computer or a personal digital assistant (PDA) that is synchronized with a computer. In some pen-based computer systems, the computer clipboard has the capability of recognizing and interpreting the user’s handwriting and converting the information he enters into an electronic format.
Computerized systems can store more information about a patient in a more legible format than written reports. The computer can be linked to diagnostic and monitoring equipment; to electronic medical records; to computer-aided dispatch (CAD); and to computer systems handling fleet management, inventory control, , personnel, and payroll. 25

26. The Minimum Data Set PCR Data Back to Objectives Talking Points
The components of the minimum data set include patient and administrative information.
In general, PCR sections include: administrative information, patient demographics and other patient data, vital signs, narrative patient information, and treatment.
Points to Emphasize
The minimum data set was established by the U.S. Department of Transportation in an attempt to improve patient care and allow comparisons between EMS services.
Knowledge Application
Students may not be familiar with military time. Explain it, then give several 12- hour clock times and ask for the military time equivalent.
Back to Objectives

27. Level of responsiveness Blood pressure
Chief complaint
Level of responsiveness
Blood pressure
Skin color, temperature, and condition
Pulse rate
Respiratory rate and effort
Patient demographics
Times of the call
Talking Points
The elements of information collected in the minimum data set are:
Patient Information
Chief complaint
Level of responsiveness (AVPU)—mental status
Blood pressure for patients greater than three years old
Skin perfusion (capillary refill) for patients less than six years old
Skin color, temperature, and condition
Pulse rate
Respiratory rate and effort
Patient demographics (age, sex, race, weight)
Administrative Information
Time the incident was reported
Time the unit was notified
Time of arrival to the patient
Time the unit left the scene
Time the unit arrived at its destination (hospital and so on)
Time of transfer of care 27

28. Administrative Information
PCR Data
Administrative Information
Discussion Question
Why are synchronous clocks important in EMS systems?
Back to Objectives

29. EMS unit and run or call number
Names of crew and levels of certification
Address to which unit is dispatched
Talking Points
The administrative information section of the PCR is sometimes referred to as the run data and includes:
The EMS unit number and the run or call number
Names of crew members and their levels of certification
The address to which the unit is dispatched 29

30. Patient Demographics and Other Patient Data
PCR Data
Patient Demographics and Other Patient Data

31. Legal name, age, sex, race, and birth date
Home address
Location where you found the patient
Insurance/billing
Care rendered prior to EMT arrival
Talking Points
This section of the PCR contains primarily demographic patient information and other pertinent data about the patient. Most systems require:
The patient’s legal name, age, sex, race, and birth date
The patient’s home address
The location where you found the patient
The insurance or billing information
Any care given before the arrival of the EMTs 31

32. Vital Signs PCR Data Talking Points
Take and record at least two complete sets of vital signs.
Record the times at which the vital signs were obtained.
Note the patient’s position at the time the vital signs were taken (supine, standing, sitting).
Critical Thinking Discussion
Why is it important to record more than one set of vital signs whenever possible? 32

33. At least two sets should be taken prior to arrival.
Talking Points
Many forms provide boxes for you to check off or write in information.
Computerized PCRs have drop-down menus that you can select or data fields where you can enter information. 33

34. Patient Narrative PCR Data Back to Objectives Point to Emphasize
The narrative is written in a simple, direct style and includes the patient’s chief complaint, medical history, and assessment findings.
Teaching Tip
Since students have not yet covered patient assessment and history-taking, give a brief explanation of the meaning of each of the components.
Critical Thinking Discussion
A patient’s family member tells you the patient is an alcoholic. How will you document the information?
Back to Objectives 34

35. Chief complaint SAMPLE Objective data Subjective data
Pertinent negatives
Talking Points
The narrative section typically contains:
The patient’s chief complaint should be in the patient’s own words or in the words of a bystander and documented in quotation marks (“my leg hurts”).
The SAMPLE history or mechanism of injury includes an account of when the chief complaint began and how it has progressed, along with other details of the patient history.
Objective information is measurable or verifiable in some way. It might be a reference to the patient’s pulse rate or a statement that the patient has discoloration below both eyes. A sign is an objective observation.
Subjective information is information based on an individual’s perceptions or interpretations. It should be pertinent and relate to the medical circumstances.
Pertinent negatives are signs or symptoms that might be expected based on the chief complaint but that the patient denies having. 35

36. Treatment PCR Data Talking Point
The treatment section should detail in chronological order all treatment you administer to the patient as well as indications of how the patient responded to that treatment. 36

37. Effect on patient status
Treatment
Time
Effect on patient status
Talking Points
An emergency physician, nurse, paramedic, or fellow EMT should be able to learn about the treatment provided, the time it was provided, and whether the patient improved or deteriorated since then.
Include any other information that may be a local or state requirement. Specific data may be collected for registries or local/state databases for the purposes of research, education, or service performance. 37

38. Legal Concerns Back to Topics Teaching Time 30 minutes Talking Points
Legal concerns involving PCR documentation include:
Keeping patient information confidential
Distributing PCR information
Documenting refusals of treatment
Avoiding falsification of information
Correcting errors
Back to Topics 38

39. Confidentiality Back to Objectives Point to Emphasize
Information on the PCR is considered protected health information under the Healthcare Information Portability and Accountability Act (HIPAA).
Back to Objectives 39

40. Information on PCR is confidential Be familiar with HIPAA
Talking Points
You must use care and discretion when handling any information about a patient.
Confidentiality is the patient’s legal right.
Information on the PCR is considered confidential protected health information under HIPAA.
Do not show the form or discuss the information on it with unauthorized individuals.
Critical Thinking Discussion
How could sharing a patient’s protected health information result in harm?
Information on PCR is confidential
Be familiar with HIPAA 40

41. Distribution

42. Follow state rules and local protocol for PCR distribution
Talking Points
Follow state rules and local protocols when distributing the PCR and any additional information about a patient encounter.
By law, you are generally permitted to provide confidential information about a patient to a health care provider for continued care of a patient, to police for a criminal investigation, to a third party for billing, or to a court if required by a legal subpoena.
Leave a copy of the PCR with the patient in the emergency department or receiving facility.
The original is typically retained by the emergency medical services.
A third copy may be forwarded to medical oversight or a quality improvement official.
Electronic data may be transferred and distributed in a similar manner.
Follow state rules and local protocol for PCR distribution
Leave a copy of PCR at receiving facility
(© Ray Kemp/911 Imaging) 42

43. Refusal of Treatment Point to Emphasize
Situations in which a patient refuses treatment require you to document that the patient understands the situation and the consequences of refusing care.
Teaching Tip
Prior to class, devise a scenario with an assistant so that you can role play obtaining a refusal of treatment for the class.
Class Activity
Using the role-play under Teaching Tip, have students document the pertinent information from the refusal. Ask for volunteers to read their documentation aloud.

44. Document your efforts completely Have patient sign refusal
Document competency
Document your efforts completely
Have patient sign refusal
Offer patient alternate methods of getting care
Remind patient that EMS can always return
Talking Points
With a patient who is refusing treatment, document your efforts completely:
If the patient refuses to accept emergency care and/or transport, document any assessment findings you made, any emergency medical care you gave, and the explanation you gave the patient about the consequences of failing to accept care and/or transport including potential death.
Document if the patient refused to allow you to complete any or all of your assessment and if the patient refused any or all emergency care you intended to provide to him.
You must document that the patient is alert and oriented to time, place, and person/self so there is no question that the patient understood the information and instructions you gave him.
Have the patient and a witness sign a refusal-of-care form. If the patient refuses to sign, have a witness sign the form verifying that the patient refused.
Always remind the patient that you are willing to return at any time. 44

45. Falsification Talking Points
Certain areas of the PCR are more commonly falsified than others.
One of those areas is vital signs. An EMT might, for some reason, neglect to take a set of vital signs and be tempted to make up numbers to cover his omission.
Another area is treatment.
Point to Emphasize
Regardless of the circumstance, an EMT should never falsify information in a PCR.

46. Do not try to cover up mistakes Do not compromise patient care
Talking Points
Since the PCR documents the nature and extent of emergency medical care an EMT provides, any medical care error must be documented on the PCR. In such a situation, the EMT might be tempted to falsify the PCR.
Never be tempted to falsify information on a PCR. When an error of omission or commission occurs, do not try to cover it up. Rather, document exactly what did or did not happen and what steps were taken to correct the situation.
False information may lead to suspension or revocation of EMT certification or license and, potentially, to criminal charges.
Falsification of patient data could compromise patient care and give other health care providers an incorrect impression of the patient’s condition from false assessment findings or a falsified report of treatment.
Discussion Question
How could patient care be affected by false documentation?
Do not try to cover up mistakes
Do not compromise patient care 46

47. Correcting Errors Falsification Point to Emphasize
Always use acceptable methods of correcting errors on the PCR.
Discussion Question
You have inadvertently written that a patient is 58 years old instead of 68 years old. What is the acceptable way of correcting this on a written PCR?

48. Draw single line, initial it, write the correct information beside it
Do not erase
Do not write over
Talking Points
When an error occurs while writing a paper report, draw a single horizontal line through the error, initial it, and write the correct information beside it. Do not try to erase or write over the error because such actions could be interpreted as an attempt to cover up the mistake or falsify the report.
When an error is discovered after the report form is submitted, use a different- colored ink to draw a single horizontal line through the error. Add a note with the correct information. Initial the entry and include the date and time of the correction. If information was omitted, the EMT should add a note with the correct information, the date, and the EMT’s initials. Be sure to bring such changes to the attention of those to whom you submitted the incorrect report.
Most electronic PCR formats provide a method to amend the report if an error is discovered. If there is no way to electronically amend or submit an amended report, correct a printed copy using the traditional methods described for a paper report and resubmit the PCR as a corrected copy.
Back to Objectives 48

49. Special Situations
Teaching Time
30 minutes
Back to Topics 49

50. Transfer of Care Report
Point to Emphasize
If it’s not possible to leave a complete PCR at the facility, an abbreviated transfer of care report will help maintain continuity of care. However, it does not replace the PCR.

51. Obtain a signature from the medical professional who is assuming care
Leave a copy of report with facility
Talking Points
Under ideal circumstances, the EMT will complete a full PCR and leave a copy with the facility. However, this ideal situation may not always exist. Your unit may need to return immediately to service to answer an additional call, precluding you from submitting a full PCR until a later time.
An abbreviated transfer-of-care form or “drop report” may be used to provide minimal patient data and collect a transfer-of-care signature. This abbreviated report can be used as a reference at a later time when completing the full PCR. Submit a copy of the transfer of care report with the full PCR. 51

52. Multiple-Casualty Incidents
Talking Points
During MCIs, rescuers are often unable to complete full documentation due to the overwhelming number of patients requiring treatment.
In these cases, you seldom have enough time to complete the standard PCR before turning to the next patient.
Point to Emphasize
An abbreviated form or triage tag may be used to record essential patient information in multiple-casualty situations.

53. Follow local MCI plan for record keeping Use triage tags
Talking Points
Your MCI plan will recommend a method of recording basic medical information during an MCI, including a way to keep that information with the patient as he is moved for treatment and/or transport.
Record basic information, such as chief complaint, vital signs, and treatment provided, on a triage tag that is attached to the patient.
Information from the tag can be used later to complete the PCR.
In MCI situations, the PCRs will usually be less detailed than those of more typical, single-patient runs.
Local guidelines should dictate what is required on PCRs after an MCI.
(© Stephanie Ruet/Corbis Sygma) 53

54. Special Reports Point to Emphasize
State and local laws may require additional documentation. Examples include employee injury reports and suspected child and elder abuse reports.
Teaching Tip
Provide examples of special reporting forms used locally.
Discussion Question
Why is it important that some events be recorded separately from the PCR?

55. Injuries to EMS members Information for other agencies
Suspected abuse
Exposures
Injuries to EMS members
Information for other agencies
Talking Points
In some circumstances, EMTs must complete special documentation such as:
Suspected abuse of a child or elderly person
Possible exposure to an infectious disease (meningitis, hepatitis, TB, HIV)
Injury to an EMS team member
Other situations that the EMT feels might require special documentation and/or notification of another agency (incident reports)
(© David Handschuh) 55

56. Alternative Documentation Methods
Teaching Time
60 minutes
Points to Emphasize
EMS systems may or may not require a specific format for the PCR narrative.
It is critical to use only standard charting abbreviations.
Teaching Tip
Explain that this introduction of documentation is necessary to structure students’ thinking about collecting information and that they will increase their understanding of documentation throughout the course.
Back to Topics 56

57. SOAP Back to Objectives Point to Emphasize
The SOAP mnemonic is often used by nursing and other health care professionals.
Teaching Tip
Hand out photocopies of a fictitious PCR and explain the method used to format the narrative.
Back to Objectives

58. S – Subjective O – Objective A – Assessment P – Plan Talking Points
S – Subjective refers to information the patient must tell you, such as information or symptoms you cannot see or feel during the physical exam.
O – Objective refers to information you identify in the physical examination through inspection, palpation, and auscultation.
A – Assessment refers to the field assessment or the general idea you form about the patient’s condition based on information you have collected. Your assessment comes from the subjective and objective components, the scene assessment, the chief complaint, and any other information provided by bystanders or family.
P – Plan refers to the plan of action and the emergency care provided to the patient. 58

59. CHART

60. C – Chief complaint H – History A – Assessment R – Rx T – Transport
Talking Points
Another mnemonic used to organize documentation is CHART:
C – Chief complaint of the patient
H – History of the patient (including the SAMPLE history)
A – Assessment findings gathered in the primary assessment, secondary assessment, detailed physical exam, and ongoing assessment
R – Rx for treatment that was provided to the patient
T – Transport any change in the patient’s condition en route and the type of transport (e.g., emergency) 60

61. CHEATED Discussion Question
How can mnemonics such as these be helpful in documentation?

62. C – Chief complaint H – History E – Exam A – Assessment T – Treatment
E – Evaluation
D – Disposition
Talking Points
A more specific mnemonic used to organize documentation is CHEATED:
C – Chief complaint
H – History of the patient (including the SAMPLE history)
E – Exam: Information you find in your physical examination of the patient
A – Assessment: Field impression you derive by processing the history and physical exam findings and determining a condition the patient may be suffering from
T – Treatment that was provided to the patient
E – Evaluation: Information you find during your ongoing assessment and any improvement or deterioration of the patient’s condition you identify
D – Disposition: Transfer of patient care at the medical facility or to another health care provider.
Knowledge Application
Select a documentation method and call out various pieces of information for a PCR narrative in random order. Have students identify where in the narrative each piece of information fits. 62

63. Medical Abbreviations
Teaching Time
20 minutes
Point to Emphasize
Use standard abbreviations to avoid miscommunication.
Teaching Tip
Bring a medical dictionary to class and explain how to find official abbreviations.
Discussion Question
What are the advantages of medical abbreviations? Are there any disadvantages?
Back to Topics 63

64. Only use universally accepted medical abbreviations.
Examples:
BP – Blood pressure
bpm – beats per minute
CVA – Cerebrovascular accident
CHF – Congestive heart failure
Talking Points
Abbreviations can save time and space when writing the PCR.
Only use universally accepted medical abbreviations.
Made-up abbreviations might imply a different meaning or no meaning to other health care professionals who will read your report.
Class Activity
Read the scenario below aloud and have students write it down, using as many abbreviations as they can (without the aid of their books). Ask for a volunteer to write the scenario on the board with his abbreviations included: “The patient is a 58-year-old male who complains of shortness of breath after walking. He has a history of chest pain and takes nitroglycerin sublingually. His symptoms decrease after receiving oxygen.”
Only use universally accepted medical abbreviations.
Back to Objectives 64

65. CASE STUDY Follow-Up Case Study Follow-Up Discussion
This case study is continued from the beginning of the presentation.
Briefly remind students that they are dispatched to a vehicle collision where a moving car hit a parked car.
The driver is ambulatory on the scene and not happy to see you.

66. CASE STUDY Assessment You notice he has a bruise above left eye
You are able to calm patient
He refuses all assessment and treatment
Case Study Follow-Up Discussion, continued
You note minor damage to the vehicles.
The man who was driving the car has a slight bruise on the left side of his forehead. He is on his feet and angrily says he does not want your help.
You remain calm and polite and introduce yourselves.
He apologizes and grows calmer. He states that he swerved to miss a dog running in the street and hit the van instead. He is in a hurry and must leave.
He was never slumped over the wheel, only head down in disgust.
He is alert, responsive, and is having no difficulty in breathing.
He refuses a physical exam and refuses to answer SAMPLE questions.
You explain that it would be best that he be checked by a doctor and that head injuries often display no signs at first but can later develop into potentially life-threatening situations. He interrupts to say, “Fine, I’ll take that chance, but I am leaving.”
Your partner discreetly calls dispatch to say, “Patient is refusing emergency care and transport. We will inform you of our status shortly.” 66

67. CASE STUDY Documentation You note all pertinent findings
Document refusal
Have Mr. Makynen read and sign refusal
Suggest Mr. Makynen see a doctor or call 911 if things change
Now clear and in service
Case Study Follow-Up Discussion, continued
Recognizing that you’ll have no success persuading him to accept care, you explain that before he leaves he must sign a refusal-of-care form.
You note the mechanism of injury, the bruise to the forehead, and your initial findings regarding his alert mental status, open airway, adequate breathing, absence of bleeding, pulse, skin color, temperature, and adequate perfusion.
You document all circumstances of the incident and that the patient refused all care. You note your recommendation that the patient see a doctor and your explanation of the consequences. You add that the patient understood the consequences and still refused.
The patient and a witness sign refusal. You suggest again that the patient see his doctor and that he not hesitate to call 911 for further assistance if needed.
Your partner contacts dispatch, reports the refusal, and your unit is now clear.
Case Study Follow-Up Discussion Questions
Why should a refusal be witnessed by someone other than your partner?
Can you think of anything else the EMTs could have said or done? 67

68. Critical Thinking Scenario
36-year-old female complaining of severe abdominal pain
The patient is alert and oriented
Vital signs:
BP: 88/64 mmHg
HR: 128 bpm with weak radial pulses
RR: 24 with adequate chest rise
Skin is pale, cool, and clammy
SpO2 is 96 percent on room air
Critical Thinking Discussion
This critical thinking scenario is intended to challenge your students to think about how to collect, record and document multiple pieces of critical patient care information while managing and transporting a deteriorating patient.
The scenario continues on the next slide.

69. Critical Thinking Scenario
SAMPLE history:
S – Feels light-headed and dizzy every time she stands up; she’s also nauseated
A – No known allergies
M – Over-the-counter Claritin for allergies
P – No pertinent medical history; tonsils removed when she was ten years old
L – Nothing to eat or drink for seven hours
E – Has “not felt real good” for a few days
Critical Thinking Discussion, continued
The scenario continues on the next slide.

70. Critical Thinking Scenario
Pain assessment:
O – Pain began suddenly and has progressively worsened; was sitting on the couch watching television when it began
P – Nothing makes it better or worse
Q – Dull, aching, and intermittent
R – Nonradiating
S – Eight out of ten
T – Four hours
Critical Thinking Discussion, continued
The scenario continues on the next slide.

71. Critical Thinking Scenario
Physical exam:
Pupils are equal and sluggish to respond
Breath sounds are equal and clear bilaterally; no JVD
Abdomen is rigid and tender; no evidence of trauma to the abdomen
Good motor and sensory function in all four extremities; peripheral pulses are very weak
Critical Thinking Discussion, continued
The scenario continues on the next slide.

72. Critical Thinking Scenario
Repeat vital signs:
BP: 82/62 mmHg
HR: 134 bpm, radial pulses barely palpable
RR: 26 with adequate chest rise
Skin is more pale, cool, and clammy
Pulse oximeter reading “error”
Critical Thinking Discussion, continued
The scenario continues on the next slide.

73. Critical Thinking Scenario
En route to the hospital, the patient begins to close her eyes
You must verbally instruct her to open her eyes
For your PCR documentation:
Jennifer Sampson
1321 Oakridge Drive
Smithville, Ohio
Critical Thinking Discussion, continued
Ask students to briefly discuss the scenario before moving on to the series of questions on the next slide.

74. Critical Thinking Questions
What can this information be used for?
How will the medical personnel in the medical facility use the information?
What will your EMS use the information for?
What would you document in the patient information section of the minimum data set?
Critical Thinking Discussion, continued
Answers:
The information can be used to ensure the continuity of care, as well as the data needed for insurance and billing, statistics, education, research, and quality improvement.
The medical staff at the receiving facility is most concerned with continuity of care and will likely use the information from the PCR to determine what the EMTs found during their assessment of the patient and what treatment occurred prior to arrival at the hospital.
EMS systems use the information from PCRs for billing, insurance reporting, educating other EMS personnel, and research studies.
The patient information section would include the patient’s chief complaint (severe abdominal pain); mental status (alert and oriented deteriorating to verbal); blood pressure (88/64); skin color, temperature, and condition (pale, cool, and clammy); pulse rate (128); respiratory rate and effort (24 and unlabored with adequate chest rise); and patient demographics (36- year-old female).

75. Critical Thinking Questions
What would you document in the administrative section of the PCR?
What information would you write in the patient narrative section?
Should any of the information not be reported in the PCR?
If you were to make a mistake while writing the PCR, how would you correct it?
Critical Thinking Discussion, continued
Answers:
You would document all times (time incident reported, time unit reported, time unit arrived, time unit left scene, time unit arrived at destination/hospital, and time care transferred), as well as other run data (unit number, run number, names of the crew members and cert levels, and address to which the unit was dispatched).
A brief sample narrative for this patient might read, “Arrived on scene to find a 36-year-old female c/o sudden onset severe abd. pain 4 hrs. ago, progressively worsening to 8/10 pain now. Sitting on couch watching TV at onset. Pt. states has “not felt real good” for a few days. Pain is dull, aching, intermittent, non-radiating. Nothing makes pain better/worse. Nauseated, light-headed, and dizzy on standing. NPO x 7 hours. No JVD. Abdomen rigid and tender, atraumatic.”
Avoid documenting nonpertinent and irrelevant information on the PCR. In this case, although some of the information is minor, it is all pertinent.
If it is a paper PCR, draw a single horizontal line through the error, initial it, and write the correct information beside it. Do not erase or write over the error. If it is an electronic PCR, use the appropriate method to amend the error.

76. Critical Thinking Questions
If the PCR contains a box for a third set of vital signs, what would you document in this patient?
How would you collect additional information needed for your PCR?
Critical Thinking Discussion, continued
Answers:
A third set of vital signs was not obtained, so depending on local procedures, the you would either leave the field blank, draw a single line through it, or write “N/A” (for Not Applicable ).
The value of doing a good assessment means going beyond the patient assessment. Assess the scene by looking around the patient’s environment, checking prescription bottles, and talking with family members, bystanders, or other emergency personnel on scene.

77. Reinforce and Review Please visit www.bradybooks.com
and follow the myBradykit links to access content for the text.
Please visit and follow the MyBradyKit links to access content for this text. Under instructor resources, you will find curriculum information, lessons plans, PowerPoint slides, TestGen, and an electronic version of the instructor’s edition. Under student resources, you will find quizzes, critical thinking scenarios, weblinks, animations, and videos related to this chapter—and much more.