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Disclamer:  This was written for a spescific organization (SBVAC).  It was written for the New York State PCR.
It was suggested by a friend of mine that it is funny enough that it has a place in the humor section of my web page, so here it is, use in good health, and hope you get a chuckle outta it.

Also keep in mind that in the examples the (-) over a c or s indicating with or without could not be coppied to HTML format.

 

How to write a PCR

 

Ok most things are self-explanatory. Patient's name, address, DOB, age. Etc. Then there are a few numbers and codes you have to fill in.
Date: DUH!
Run number: leave blank we don't us it
Agency code: 08118 (for SBVAC)
Vehicle ID: 53516 or 53517 or 53580 depending on your vehicle
Location code: 5151 (town of brookhaven)

Ok now when do you have to write a PCR:

 

OK now the really hard part the real writing! ARUGHHHH!

 

Chief complaint: should be a direct quote from the patient i.e. " I feel sick", "my stomach hurts" it should also be in quotes. Even if it has nothing to do with why you are there. If the patient is unconscious/ unresponsive, you can write that in. If they are in cardiac or respiratory arrest write that in. If they have no chief complaint put "none stated"

 

Subjective assessment: an expansion to the chief complaint. How exactly does the patient feel? How were they found, in care of someone else? In an MVA the location of patient (driver etc.) damage to vehicle, steering wheel, pedals, dashboard, seat.

Usually starts off: Pt. found (sitting, lying down, in care of etc) c/o (chest pains, nausea, arm pain, etc.)

 

Objective physical assessment: Your findings. The more you document the better. Does this show you did a full assessment? A good way to start is to run through primary survey : Pt. A + Ox3 (or other mental status) [check for responsiveness]Lung sounds (clear, wheezes, rails, etc) (bilat, lt side, rt side), (-/+) SOB, (-/+)JVD, trach (midline, deviated, lt. rt.) [primary A +B] perif pulses (good x 4, weak or absent in (specify extremity)) [primary C] neuros (good x 4, weak or absent in (specify extremity)) [primary D]

Then put your physical findings i.e.: a Lac to (wherever and size), bruising to (wherever).

If there are no physical findings then put " 2nd survey unremarkable"

 

Comments: anything else important, did the patient's condition change. In an MVA was the patient walking around, or self extricate. This is the Cover Your Ass section. Also used for the continuation of physical assessment. Also anything that someone other than the crew or patent said and start it off whoever states (PD states "bla bla bla")

 

Examples:

1.chest pain

Chief complaint: "My chest fucking hurts like hell"

Subjective assessment: pt. c/o substernal crushing chest pain radiating to the lt. arm x3 hours. Pt was working out when pain started. Pain is a 7 on scale of 10.

Objective physical assessment: Pt. A+Ox3 lung sounds clear bilat, +SOB, -JVD, trach   midline. Good neuros and perif pulses x4. + pedal edema, minor respiratory distress, s accessory muscle use.

 

Comments: Pt's pain decreased from a 7 to a 5 c O2. Pt. transported s incident Pt's Wife states that he drank 3 beers before working out, pt denies this.

2.MVA

Chief complaint: "my head hurts"

Subjective assessment: Pt. found in driver seat c/o head and neck pain from a high speed MVA Head on collision.

 

Objective physical assessment: Pt verbally responsive lung sounds absent on rt. Side, +JVD, Trach deviated to left. Brusing to chest, Weak neuros both feet, weak pedal pulses. Lac to forehead ~4in deformity and bruising to RT forearm, Lac to lt. shoulder ~ 3in rigidity and point tenderness in upper abdominal quadrants. Compound lt. fib-tib Fx. +SOB c accessory muscle use. + LOC unknown time

Comments: major damage to front end of vehicle, broken windshield by driver side, seat dismounted, steering wheel bent forward, dash dismounted, brake pedal bent. Pt's mental status decreased while enroute to hospital, but still considered verbal.

3. Overdose

Chief complaint: "The rats are pink"

Subjective assessment: Pt found on floor at a party verbally responsive c/o seeing pink rats

Objective physical assessment: Pt verbally responsive, lung sounds clear bilat, neuros and perif pulses good x4. 2o survey unremarkable

Comments: bystanders state pt. was unc/unresp for 5 min prior to our arrival, and pt had a bottle of JD, 6 beers, 5 shots of tequila, and smoked some marijuana.

4. Minor MVA

Chief Complaint: "My neck hurts"

Subjective assessment: Pt was found sitting on curb c/o neck pain. Pt was in a minor MVA rear end collision ~5 mph. No damage to interior of vehicle. Minor damage to rear bumper.

Objective physical assessment: pt. A+Ox3 lung sounds clear bilat, neuros and perif pulses good x4. 2o survey unremarkable -LOC

Comments: Pt. states they got out of car by themselves. PD and bystanders state that pt. was walking around prior to our arrival. Air bags did not deploy.

 

 

Notice that the sections are not always perfectly organized. This is because you will forget to put things and will have to add them at the end, or in the comments section. This document is also not the gospel on writing PCR's according to me (well it is but you know what I mean). It is a suggestion on how to make sure you document what is important in the sections that you have to write all the information.

Please remember to look over the other sections that only require you to check boxes and circle. I felt that I did not have to explain these sections, but if you need any help please contact me or whoever the present 31 is if this if used in the future

 

Copyright 6/19/97 The Lunatick

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