By: David March, Training Officer, 2014
A Pre-hospital Care Report (PCR) that describes the call in the broadest strokes possible may exclude useful information that could have an impact on treatment and diagnostic decisions. On the other hand, voluminous reports for every call end up burying useful information in a pile of irrelevant details. Although when in doubt it is always better to include questionable details, it is worth investigating what ideally belongs in a PCR.
A good PCR covers the entire time-line of the call; including as good a history as possible, a detailed description of your time on scene, and a short note about the patient’s disposition. An extensive history is vital for most medical calls, while trauma calls more often only need an explanation of the events leading up to the incident and an on-scene description. Be sure to note who provided which details and their relationship to the patient. The description of your time on scene should include everything that seems relevant to the patient’s condition, as well as anything very unusual. Summarize repeated behavior; if the patient responds inappropriately to your questions, note this, not all of their responses. Brevity here will help highlight the crucial facts about the patient’s condition.
Dispositions are straightforward, but are crucial from a liability standpoint. As a patient advocate, it is your responsibility to ensure they will be taken care of. Note what agency took control, what they’re planning to do with the patient, and if any difficulties arose in transfer. In addition to providing details about the patient, a PCR provides an explanation and justification for your decisions on scene. If a patient is RMA’d make sure anyone reading the report can tell you had good reason to feel comfortable leaving them on their own. A PCR is a record of your decisions on scene, and anyone reading it should understand your thought process. This is impossible if you don’t include the necessary facts of the case, but it also is severely hindered by unnecessary, irrelevant details.
Completeness comes before conciseness. Always include any details that you think are pertinent to the call. However, whenever possible, ask yourself if a particular note adds anything to your report or if it simply fills up space. All those who need to consult your notes further down the line will appreciate it.