Documentation: Patient Care Reports
EMS Professions Temple College
Uses of the PCRs
Continued Medical Care Administration of the EMS system Clinical Research Legal Concerns
Medical Documentation Concerns
Illegible hand-writing Inappropriate or inaccurate medical terminology Inappropriate or non-standard abbreviations/symbols Alterations to the report Overall Unprofessional Presentation
The SOAP Format
Subjective
told to you something you can’t verify, measure or determine on your own “hearsay” Generally includes the mechanism and damage to vehicles in cases of MVCs
The SOAP Format
Objective
Information you know as fact Data that can be verified, measured or gathered by you What you see, smell, hear or do What you know for certain! Your initial observations of the scene & patient
The SOAP Format
Assessment
Your impression of the underlying problem Your diagnosis when possible Your overall assessment of the patient’s illness or injury(ies) May not be known for certain May be a differential diagnosis BUT MUST be brief and specific
The SOAP Format
Plan
What have you done What are you planning to do Should be in chronological order May include disposition of the patient
Where patient went Who received patient and report
Other Possibilities
Other documentation methods
CHARTE Chronological Bubble Sheet
Electronic Documentation
Example PCRs
Sample PCRs Practice Case