Monday, June 13, 2011

PCRs on the run

Been reading some great stuff about patient assessment this morning, over on Ckemtp's blog, Life Under the Lights.  Followed the links at the bottom to some previous posts he has made on the topic, and also, one about writing good patient narratives.

Writing a great narrative is definitely a skill, and any skill requires practice.
I especially like his suggestion (he's not the only one who suggests it, but it was his blog I was reading today) to think about what you are going to write, organize it in your head, and afterwards, re-read it.  Have your partner re-read it. It's a great idea.

Unfortunately, it is of limited use in the situation in which we typically find ourselves. We simply don't have much time.

Being non-transporting means that another agency transports the patient.
What this means for us as far as the written report, the narrative, the PCR, is that we have to write it FAST because one copy goes with the ambulance.

If we make changes or additions after that, that information has to get to where the patient is, either by fax or by hand delivery. 

Yes. We still use paper PCRs. It's going to take a while to haul the dept out of the dark ages, for a variety of reasons.  We don't have a computer, of any kind, available to anyone other than the line officers and company secretary.  No computer, no e-PCR. What I wouldn't give some days for an iPad.

It has never been made clear exactly what the procedure is for faxing the information without violating HIPAA. There was a period of time when we did not have access to a fax machine.  So basically, we don't fax to the ER.  I HAVE hand delivered a PCR a few times, when it was an intense call that needed a LOT of narrative, and we didn't get ANY of it done before the ambulance left because we were too busy with patient care.

Most of the time, by far, I end up filling out the PCR for the simple reason that I write fastest.  Well, that, and I'm the EMT in charge on the call, and often the only one there, but that's beside the point at the moment.  But back when I wasn't the only EMT, I still wrote fastest, so I've gotten the most experience with writing the things for the past several years.

What happens NOW is that sometimes, someone else will want to help with the PCR. This is GREAT.  I need to be providing patient care, not secretarial support.  The problem comes when that person doesn't know HOW to do a PCR.  They may not know where the information goes, or which information they should be writing down. Even people who you'd think would know how to do this, people with "years of experience," don't always do it very well.

Having a partially filled in and written on PCR handed to me between the door of the house and the back door of the ambulance, for me to finish and hand off to the ALS crew, which is filled with errors and stuff in the wrong place is REALLY ANNOYING, PEOPLE. Seriously.  I either have to quickly cross out and re-write and scramble and end up with a PCR that looks like CRAP, or I have to scrap the entire thing, and figure out how I'm going to get the new one up to the ER.  

Not to mention: if a copy of my PCR does not go with the ambulance, then all that information I gathered before the medics arrived, THEY WON'T HAVE ACCESS TO IT.  And that is not a lot of help, to anyone.  Some of the time, it doesn't matter a whole lot. But on a call where we actually do something that improves the condition of the patient, so what we found when we got there, and what the medics see, are very different- it would be good for that information to be available.  

I have picked up a few pointers on getting a decent PCR written in a very short period of time, on scene.

1. Start before you get there.  Some of the information, you already know. Assuming you are not driving, start to fill out the form on the way.  The date, agency code, location code, apparatus number, whether it's an emergency or not, whether it's a residence or somewhere else, your agency's name, what dispatch said and the address of the call are all known to you before you arrive. So fill that part in.  They can be filled in by anyone, not just an EMT.

2. You may also know who is responding.  In charge, Driver, and the rest of the crew can be filled in on the bottom before you get there, much of the time.

3. Learn your way around the PCR. If you are doing the writing while an EMT is providing patient care, know what bits of information to be listening for, and where they go. Name, birthday, medical conditions, medications, blood pressure, respiration, pulse... these all have places to go on the form, and you'll hear them spoken out loud.

4. Once at the call, be alert for any information that needs to go on the form. Listen for it, and prioritize it. For example, you can write in the patient's address, especially if it's the location of the call, at any point, so if you are in the middle of that, and hear some of the priority information, STOP writing in the address, go write in the priority information, and come back to the stuff that you already know.  Especially prioritize numbers.

5. Practice outside calls. Have someone do an assessment, and verbalize their findings, and have another person put that information on a PCR.

6. If you are NOT the EMT in charge, don't fill in the narrative UNLESS the two of you have an agreement, and an understanding of how to write it.  PLEASE don't just start writing stuff wherever you want, in whatever order you want. I swear, if anyone hands me another PCR that has obscure codes scribbled in my narrative spaces, and subjective information in the objective space, or vice versa, with no space left to write the information I actually need to have there, I'm going to smack someone. My partners already know that there is one person who I do not want touching my PCR, ever, on a call, and they are well informed in keeping the clipboard away from that person.  But he's not the only one who has written stuff where it doesn't belong.

7. If you really, really want to write ANYTHING in the narrative spaces, PLEASE do yourself and me and the rest of the universe a favor, and learn the DIFFERENCE between "subjective" and "objective." It's not hard. Short version: subjective is what they tell you, what they feel; objective is what you observe, what you measure and what you do.

8. There are a couple of times during the call that are generally best suited to writing.  Some of it depends on the condition of the patient. 
  a) If you have help, and the patient is alert and oriented, if your general impression is good, then you can write as you gather the information. Maintain connection with the patient, don't just stare at the page, but you should be able to fill in a lot while you are having a conversation.
  b) If the patient is unstable, or you don't have help, you may not be able to write much while doing the assessment. In that case, use the time from when you transfer care to the transporting agency, until the patient is in the ambulance, IF you are not needed to help with continuing patient care. I write narratives between the doors, often. I follow the stretcher, writing madly as I go. Do the narrative then, quickly check to see that all your boxes and been filled and checked. Have a method for the checking so you don't miss anything.
  c) If you ARE needed, obviously, the patient is more important than the paperwork. 

9. Be observant. Learn to experience the call with the narrative developing in your head as you go.

10. This may seem obvious, but perhaps not. Practice writing narratives. Practice the order you want to put information in so you don't have to think about it.  If you have a running narrative in your head, it will be easier to write it down.  "The patient was found... <level of consciousness>," etc. "Patient reports having...<various symptoms and experiences>  denies...<critical negatives>."  Come up with a method that works for you, and use it. If you know of people who write great narratives, use them as role models. There is a pair of medics near here who write exceptional narratives, and I learned a LOT by riding with them and seeing how they organize information.

11. Don't be afraid to use a continuation form if you need one. And if it simply can't be done, having a finished PCR ready to go with the ambulance, then it can't. Don't sweat it. Fax it if you can, or deliver it, or whatever is necessary to keep that information with the patient. There shouldn't be many times that this happens.

12. A small, but important thing: have extra pens. I keep one attached to the PCR clipboard, and two extras inside it. I also carry a "space pen" that can write on wet paper. It doesn't take long for a PCR to get soaked out in the weather!

It would be great if we had the luxury of writing the PCR after the call, when we're back somewhere dry and reasonably comfortable, but we don't. Even so, with good practice, good planning, and doing as much as possible on the way there, it is possible to produce a reasonably good PCR in a very short period of time. They key is knowing what needs to be on it, and where that information goes, so you don't waste any time hunting around for anything.

Over on his blog, Chris says "EMS documentation doesn't have to be hard, It doesn't have to be tedious, and it certainly doesn't have to be done poorly to save time."  
I agree.  
You can save a LOT of time with good planning and organizational skills, so that you do not sacrifice quality when you have no time to spare.

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