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Report Overall Unprofessional Presentation - PDF by nja90133

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Report Overall Unprofessional Presentation document sample

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									     DOCUMENTATION:
PATIENT CARE REPORTS




EMS Training Programs
Imperial Valley 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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