PCR Purpose & Structure
The primary written record of patient care completed by EMTs that serves medical, legal, administrative, and research functions.
The primary written record of patient care completed by EMTs that serves medical, legal, administrative, and research functions.
Federal law governing patient privacy and strictly restricting who may access PCR information.
What is HIPAA?
During Multiple-Casualty Incidents (MCIs), EMTs track essential patient vitals, complaints, and treatment using these.
What are triage tags?
In the SOAP narrative format, the letter "S" stands for this section containing patient complaints.
What is Subjective?
Standard medical abbreviation representing shortness of breath.
What is SOB?
Signs or symptoms that are expected based on the patient's chief complaint but are absent upon assessment.
What are pertinent negatives?
Proper procedure for correcting a written error on a paper PCR involves drawing a single line through the mistake and adding these two items.
What are initials and the date?
A preliminary documentation tool used when a full PCR cannot be completed prior to leaving the emergency department.
What is a transfer-of-care report?
Documentation mnemonic where "C" stands for Chief Complaint and "H" stands for History.
What is CHART?
Medical abbreviation indicating a patient has no known drug allergies.
What is NKDA?
Patient-reported symptoms such as nausea or severity of pain that cannot be independently measured by the EMT.
What are subjective findings?
If a competent patient refuses care and refuses to sign the refusal form, the EMT must document the refusal and obtain a signature from this person.
Who is a third-party witness?
Name two crime or safety situations that require submitting a special report beyond the standard PCR.
What are suspected child/elder abuse, gunshot wounds, or suspicious burns?
The letters "I" and "E" added to the SOAP format to form SOAPIE represent these two clinical steps.
What are Intervention and Evaluation?
Exact statements or quotes made by the patient should always be placed inside these in the narrative section.
What are quotation marks?
The standard set of administrative and patient baseline information established by the U.S. Department of Transportation for PCRs.
What is the Minimum Data Set?
A formal addition or update made to a completed PCR that must be separately dated and signed.
What is an addendum?
Occupational safety incident involving the EMS crew that mandates an immediate special report.
What is an infectious exposure or EMS provider injury?
Component represented by the letter "A" in both SOAP and CHART narrative structures.
What is Assessment (field impression)?
Medical abbreviation used to document an abdominal aortic aneurysm.
What is AAA?
Minimum number of vital sign sets that must be documented on a standard PCR, along with time and patient position.
What is two sets?
A cardinal rule of EMS documentation specifying the illegal act of altering, fabricating, or falsifying patient data.
What is falsification?
Obligation an EMT must fulfill after leaving a temporary transfer-of-care report at the hospital.
What is submitting the full PCR later?
Narrative format mnemonic standing for Chief Complaint, History, Exam, Assessment, Treatment, Evaluation, and Disposition.
What is CHEATED?
Essential documentation principle regarding the record of interventions performed during patient care.
What is "document what you did, not what you intended to do"?