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Documentation: Patient Care Reports

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					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

				
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posted:3/28/2008
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