Writing PCR's for school

[EMTDriver]

Hello everyone. Last night in class we started learning documentation. They really stressed that PCR's can and probably will save your bacon at some point in the career. We did a small scenario and filled out a trip report for that scenario. Anyways, I do realize that because it was my first time writing one, it will not be great, probably won't be just "good" either. It was really fast and I felt I missed 80% of what was said in the scenario... So my question is; does anyone have any tips or tricks, things I should practice, etc? I really want to get to the point where I can write a GREAT PCR. If anyone has any pointers or maybe a link to some practice sheets or whatever I would really appreciate it!

Trent

 

[mgr22]

In your objective assessment, consider summarizing head-to-toe. Doing it that way every time lessens the chance you'll forget something. Be sure to include pertinent negatives.

 

[planetmike]

Like everything in EMS, it gets easier as you do more. Try to come up with a standard format, and use that same format for every report. That minimizes the chances of you forgetting something.

 

[Jason]

Both of the above are so very correct. I've been in EMS and a paramedic for many years, and there are still times when I think: I should say something more. My reports have been reviewed before and I've been told that they're not bad. And in some cases, helped me a lot.
I use a systematic approach, like head to toe, each time. My current OMD likes us to use A.C.H.A.R.T.D.(E.) as a guide to PCRs. ACHARTD can be googled for more info. My A-Assessment: is a head to toe and a follow up on findings relavent to patient care.
Hope this helps.