PCRs

[Guest]

Does anyone have any good links for websites that explain some useful acceptable PCR abbreviations? Sometimes I feel that I'm writing too much, and other times I'm afraid that if someone were to actually read my PCRs they wouldn't know what abbreviations.

i.e. recently I saw an EMT write "NKMA" to indicate "no known medical allergies." That's the sort of abbreviation that I'm wondering about.

Thanks!

Edited August 7, 2005 by anon311

[ems-buff 81]

I got this from a friend who got this from a medic we use to work with:

Subjective: What the patient tells you.

U/A fd age y/o sex position found (supine, sitting, standing etc and on floor, in chair, in bed etc) C/A/O x 3 (person, place, time). If not 3, document why, such as alzheimers etc. Include if anyone on scene, such as PD, Medic, FD (include any treatment they are doing such as providing O2 ) etc.

Chief Complaint (c/o) Include quality of pain, scale, relieving factors, precipitating factors, duration, etc.

Brief Hx of incident

Medical History; (Med Hx)

Objective:

Physical Examination:

· LOC: + or -

· Pupils: PERLA: Pupils equal and reactive to light and accommodation

· Headache (H/A) Dizziness

· SOB: (Shortness of Breath); Describe if mild, moderate, severe etc, accessory muscle use, tripod position.

· JVD/Neck: (Jugular Vein Distention); Any tracheal deviation, Neck Pain

· L/S: (Lung Sounds): Clear bilat c = expansion (clear bilaterally with equal expansion) describe if any wheezes, rhonchi (coarse sounds) or rales (crackles/bubbling). If the patient has a cough, find out if it is dry or productive; if productive what color is the sputum.

· CP (Chest Pain); Describe if increases in inspiration and palpation, describe on a pain scale of 1 to 10 (if 10 being the worst pain you have ever felt), describe quality such as stabbing, pressure, dull pain etc. Does the pain radiate? Does anything relieve the pain or make it worse.

· Back: Where is the pain? (Cervical, Thoracic, Lumbar, Sacral) Describe the pain, does it radiate, is it relieved by anything, or made worse by anything such as movement?

· ABD (Abdomen): S/S N/T x 4Q (Soft, supple, non-tender x 4 quadrants); Describe if there is pain on palpation and in what quadrant. Is the abdomen rigid, guarded etc? Is there nausea and vomiting (N/V)? Describe vomitus (food product, bilious meaning green, or contains blood), When was the last bowel movement and describe it (such as was it black? Meaning blood or did it have fresh blood as in hemorrhoids). Has the patient urinated? Is it painful? Was there any blood etc?

· EXTR (Extremities) + PMS x 4 Extr. Positive pulse, motor, sensory x 4 extremities. Note any deformities, bruising, bleeding, etc. Noted any sensory loss or motor deficits. (as in the elderly, walks with a cane or walker or wheelchair bound)

Plan:

What did you do for the patient (Pt)?

Did you give O2?

Did you stop any bleeding and how? Such as 4x4’s and pressure or kling?

Did you splint?

Did you board and collar the patient?

Then put that you transported the patient to which hospital. (Txp to SSMC) and was there any further problems that arose.

Example: Txp pt to SSMC s (triangle means change) or incident BLS.

Did you notify the hospital? (Hosp notif. Enroute.

Common Abbreviations:

Pt: Patient

Tx: Treatment

U/A: Upon Arrival

fd: (small case): found

Txp: Transport

c/o: Complains of

Hx: History

Rx: Prescription

N/V: Nausea and Vomiting

Abd: Abdomen

H/A: Headache

L/S: Lung Sounds

c: with

s: without.

BM: Bowel Movement

[GoshenFD 0]

U/A fd age y/o sex  position found (supine, sitting, standing etc and on floor, in chair, in bed etc) C/A/O x 3 (person, place, time). If not 3, document why, such as alzheimers etc. Include if anyone on scene, such as PD, Medic, FD (include any treatment they are doing such as providing O2 ) etc.

Chief Complaint (c/o) Include quality of pain, scale, relieving factors, precipitating factors, duration, etc.

Brief Hx of incident

This is an example of where commas would come in handy. :angry:

[ems-buff 81]

you are correct sir all i did was click and paste

Edited August 8, 2005 by ems-buff

[Guest paramedico987]

I've never seen anyone use "NKMA" NKA and NKDA (for no know DRUG allergies) are known to me as acceptable abreviations.

anyway... I found this website if you want to refernce "http://www.healthmobius.com/lib/tools/R103_W1.asp"

just be careful, there are some abreviations which can mean differnt things (i.e. does "PE" mean, pulmonary embolism, pulmonary edema, pedal edema, or physical exam?)

[WAS967 97]

Yeah, show me an allergy that ISN'T medical (except maybe allergies to work). I tend to prefer NKA since it covers the whole spectrum. NKDA implies only that the patient has no DRUG allergies. There are many other things person can be allergic to so be sure to run the gauntlet - drugs, foods, environmental (bee stings, etc), and especially latex. It can also be handy to find out how extensive a person's allergy is to a certain item.

[Remember585 815]

One common phrase I put on my PCRs is "None admitted." I use this for allergies, medications, past history and even the Chief Complaint if I can't get the needed info. I also verbalize my entire impression of the patient and scene in the first part (subjective?), and put down my in-depth evaluation of the patient in the next part. (objective? I forget). Generally, in the comments area, I put transport info, and other pertinent information as needed.

One rule of thumb I go by and tell up and coming EMTs, if you don't write it down, then it never was done.

DOCUMENTATION can and will be your savior or your downfall. Make the right choice.

[WAS967 97]

Some people also put under history, medication, allergies "patient denies" just so if later the patient says they take something you can say that earlier they denied any current Rx.

[ems-buff 81]

What happen's when the Pt is unresponsive what whould you write for that? (I.E. KNDA (What i use in such a case) or unable to retrive) which one is more right to use in such a situation?

[roeems87 0]

Generally I wouldn't write "NKDA" if you never asked because that implies that none are KNOWN, i.e. you know that there are none... at least that's my impression. If I haven't done something, for whatever reason I usually write UTO, which means Unable to Obtain. Sometimes if it's a transport where the patient won't allow that BP cuff around their arm if their life depends on it, then in the BP box (for example) I would write "UTO" and if applicable, I would put "+ Radials" showing that the blood pressure is at least70 (I think that's the number, maybe 80, 60, I don't remember, somewhere in that ball park)...

Whenever something is a necessary step, and I can't do it, it gets the "UTO" and a quick explanation why not in the narrative...

[BFD1054 1,552]

Wow this was a great topic! Good questions anon311! This is a great example of how helpful these forums are!

Don't worry anon, i too feel as though i am writing a book when it comes to PCR's (which may not be a bad thing). I also do not utilize abbreviations as often as i should, which makes it more of a pain in the a$$.

Everyone had great tips and comments to share. I'll definately have to keep alot of this in mind!

[mikeinet 37]

I agree with BFD - great topic to be brought up... one thing that's always bugged me, is there is never a real "standard" to writing PCRs. Depending the part of state, EMT instructor, agency... you'll find pcr's ranging from 1 word, to 10 CCRs. I'm not sure what can be done about it, but just something to bring up.

This isnt saying that all PCRs should be the same - everyone has their own writing styles... but abbrevations should be standardized... and "what type of things" to be written should be same across the board.

[roeems87 0]

Believe it or not, NYS DOH does have a protocol type thing on how to write PCRs and goes through each section with what should be included and what things are important and what exactly the bubbles you are filling in mean. The summary written above is pretty good.

This a point I have made time and time again. Documentation is a chapter in the EMT books, but all we really learn in class is "document everything on the PCR." No real teaching on how to do it is actually done, and in my opinion, that's a shame. PCRs are one of the things you are 100% going to use and have to fill out every time you get on that ambulance. That's more than you can say about just about everything else, and we practice other skills time and time again in class. Not for anything, but I think PCR writing should be part of the patient assessment practical test. After you are done with your assessment and have asked and obtained all the information you may need (via verbal and physical exam), then you should be asked to document your findings on a PCR. That PCR should be evaluated for accuracy and thoroughness. That would ensure all EMTs out of school learned how to write and properly document the call they have just completed. That is a NECESSARY and ESSENTIAL skill that is not emphasized nearly enough in class. CYA and "document everything" are not nearly adequate learning techniques...

[Guest mediconpatrol]

Generally I wouldn't write "NKDA" if you never asked because that implies that none are KNOWN, i.e. you know that there are none... at least that's my impression. If I haven't done something, for whatever reason I usually write UTO, which means Unable to Obtain. Sometimes if it's a transport where the patient won't allow that BP cuff around their arm if their life depends on it, then in the BP box (for example) I would write "UTO" and if applicable, I would put "+ Radials" showing that  the blood pressure is at least70 (I think that's the number, maybe 80, 60, I don't remember, somewhere in that ball park)...

Whenever something is a necessary step, and I can't do it, it gets the "UTO" and a quick explanation why not in the narrative...

<{POST_SNAPBACK}>

I am not sure I like the "UTO" esepecially if the patient is refusing..That leads me to believe that you tried and were unable to get a reading. If the patient is refusing I put "refuses" and then explain in narrative. I also try to get them to sign the "refusal of treatment" section on the back of the pcr whenever possible.

[mikeinet 37]

Believe it or not, NYS DOH does have a protocol type thing on how to write PCRs and goes through each section with what should be included and what things are important and what exactly the bubbles you are filling in mean. The summary written above is pretty good.

This a point I have made time and time again. Documentation is a chapter in the EMT books, but all we really learn in class is "document everything on the PCR." No real teaching on how to do it is actually done, and in my opinion, that's a shame. PCRs are one of the things you are 100% going to use and have to fill out every time you get on that ambulance. That's more than you can say about just about everything else, and we practice other skills time and time again in class. Not for anything, but I think PCR writing should be part of the patient assessment practical test. After you are done with your assessment and have asked and obtained all the information you may need (via verbal and physical exam), then you should be asked to document your findings on a PCR. That PCR should be evaluated for accuracy and thoroughness. That would ensure all EMTs out of school learned how to write and properly document the call they have just completed. That is a NECESSARY and ESSENTIAL skill that is not emphasized nearly enough in class. CYA and "document everything" are not nearly adequate learning techniques...

I agree with you 100%! In my basic class, we actually did spend some time going over PCRs (well, not a whole lot... but he gave us a cheat sheet) - and before we could take our practical, he made us turn in 10 pcr's from our rideouts that he "graded" and would not let us take the practical until he was happy that we at least had the jist of things.

I think it would be great to be part of the practical... makes sense. I know a handful of ambulance companies make you do a "practice PCR" as part of the job interview process... good!

[21Truck 8]

I remember in my basic class we had to hand in 12 pcr's we wrote on ride alongs. I always feel i'm wiritng a novel when doing mine and use abbreviations where I can. For PMS I usually use motor neuor intactx4 and have never had anyone complain about it. I agree that documenting everything is a must because if ti's not written down it was never done. I've also found when writing my pcr's I usually go into the comments section when writing my objective and tie in whatever comments I may have into it. I'm hoping to take my medic starting the end of the month so hopefully in the class they'll go over writing pcr's alittle more to help me out to better myself

[ems-buff 81]

WOW they let you write them up back in the day that's cool

one thing i do is i find a spot in the ER that has alot less noise then i sit down and think about the call than i start writeing it up

[mikeinet 37]

WOW they let you write them up back in the day that's cool

one thing i do is i find a spot in the ER that has alot less noise then i sit down and think about the call than i start writeing it up

oh I didn't really write the PCR for the call - the instructor just made photocopies of PCRs for us to write on :-)

Either way, I'm quite happy he did it - helped a LOT!

[ems-buff 81]

no i did the same tihng in my EMT class also i thought you guys did it on the call it's self

[21Truck 8]

I was wondering if anyone used the term all physical findings unremarkable instead of writing down every little detail. My squad has one EMT who will write down what the problem is and all and then for everything else he will usually put all other physical findings unremarkable. Just wondering if others do this and if it's allowed by the region

[ems-buff 81]

Rule number one of the EMT class Cover you A$$

[HCFRFF 0]

One common phrase I put on my PCRs is "None admitted."  I use this for allergies, medications, past history and even the Chief Complaint if I can't get the needed info.  I also verbalize my entire impression of the patient and scene in the first part (subjective?), and put down my in-depth evaluation of the patient in the next part.  (objective? I forget).  Generally, in the comments area, I put transport info, and other pertinent information as needed.

One rule of thumb I go by and tell up and coming EMTs, if you don't write it down, then it never was done.

DOCUMENTATION can and will be your savior or your downfall.  Make the right choice.

←

you writing a PCR. Now thats funny!! just kiddin buddy.....good topic guys, great info

Edited October 15, 2005 by HCFRFF

[BMFD409 0]

wondering if any one had a term for alchohol breath iv always used "aob" "alchohol on breath" not really for pcrs but for saying around patient with out him/her knowing?

[ems-buff 81]

wondering if any one had a term for alchohol breath iv always used "aob" "alchohol on breath" not really for pcrs but for saying around patient with out him/her knowing?

←

I was tought to put "ETOH like odor on breath" if you smell something along the lines of alchohol. Alest's that's what i would do.

Hope this helps

[DaveTFD 0]

for a long time i have been writing "extremities ok x4". i dont know if thats acceptable and if any1 knows feel free to comment.

also to share a little pcr trick i just learned: insted of writing "ALS on scene but did not ride" (assuming u r a BLS provider), write "ALS triage to BLS". if u write novels like me in my pcrs because i like detail incase i get "THE LETTER" to appear in court, little sentence cuts are good.

good topic. i actually learned some new abbreviations from ems-buff

[mikeinet 37]

ill do pertinant negatives... and if say its a medical call put "no tramatic findings found" or something like that but still go through the negatives like CP/LOC/NVD etc.

[Guest]

I was wondering if anyone used the term all physical findings unremarkable instead of writing down every little detail. My squad has one EMT who will write down what the problem is and all and then for everything else he will usually put all other physical findings unremarkable. Just wondering if others do this and if it's allowed by the region

←

I write "All other PE (physical Exam) Unremarkable" usually after my pertinent negatives and or positives. It can at times save you from writing every little detail on your PCR. For your "routine", and I hate that word, BLS TXP PCR's it should be short sweet and to the point. No need to fil it with useless jargon. Also to note on a BLS level, do not document ALS skills. You could write something like ALS on scene and continue with your Basic PCR.

Correct me if I am wrong on any of that information, I believe that the more we can give to EMT's willing to learn, the more likely they will become great EMT's and possibly good medics.

[DaveTFD 0]

"Correct me if I am wrong on any of that information, I believe that the more we can give to EMT's willing to learn, the more likely they will become great EMT's and possibly good medics."

well put. i totally agree with u

[Guest]

My favorite PCR word is APPEARS, shows i did it but dosent commit me to anything ( as far as court is concerned .....LOL )

Just remember one thing what you write in the subjective and objective is what will be brought up in court,the state or region is mainly concerned with the right boxes being checked. So just keep that in mind these are the things the lawyers will be looking at under a microscope........

[Skooter92 7]

Documenting your observations regarding the presence of alcohol on the patient's breath or person is tough. Technically, stating you "smell alcohol on the the patient's breath/body" is legally imprecise, since you aren't really differentiating (nor are you able to) between the various alcohols (isopropyl, ethanol, methyl, propyl, etc) and substances that can smell like alcohol when on the breath or body and have similar effects on the patient (such as ethylene glycol). Your best bet is to concisely document physical findings such as dilated pupils, slurred speech, mental status and response to commands, and gait. Document as well any statements made by the patient (if not too sloshed to speak!) relevant to their presentation, as well as observations of their surroundings which help to create the overall picture you're trying to paint WITHOUT making the overt statement that the patient is "drunk/intoxicated". Both are assumptions made without specific training and/or an Intoxilyzer. You CAN document on the PCR that you "smelled an odor similar to an alcoholic beverage" on the patient' breath/body-that's a direct observation based on your senses, not an assumption.

Edited February 12, 2006 by Skooter92