When you write a patient care report, pretend that it will someday be enlarged and projected onto a giant screen for a court of law and the general public to scrutinize. These questions should pop into mind:
- How is my spelling?
- How well are my thoughts organized?
- What do these things say about me?
- How did I add to or change an automated narrative?
There are simple concepts and tips to keep in mind whenever you write a PCR:
- Spelling. Make sure that your spelling is correct. When in doubt, look it up or change the word.
- Abbreviations. Use only approved and recognizable medical abbreviations.
- Demographics. Double-check the patient’s name, date of birth and other identifying information to ensure accuracy. If you are unsure, document the reason(s).
- Completeness. Double-check each checklist box to make sure that everything is covered. There’s nothing quite like noting that a glass eye is equal and reactive to light. I have seen it done.
- Time. Employ a consistent method for tracking time and documenting travel times, treatment times and changes in a patient’s condition.
- Descriptive. Be sure to describe what you see and hear (and smell, if necessary) throughout the call.
- Attribution. Identify and attribute statements made by others, especially statements about what happened prior to your arrival.
- Vivid. Be an artist and paint a picture! Organize a detailed sequential narrative of the call from inception to the emergency room.
If you are using a hand-off form make sure to print clearly in black ink (unless your agency requires blue).
This article, originally published on February 29, 2008, has been updated.
