NREMT EMT 3: Secondary Assessment - Documentation of Findings, PCR/ePCR Narrative Report Writing

What This Is: Documentation of Findings (PCR, ePCR, Narrative Report Writing)

Documentation of findings is like writing a detailed report after a mission. It helps EMS teams remember what happened, what they did, and what worked or didn't work. This information is crucial for patient care, medical research, and even court cases. Think of it like a police report after a car accident – it helps piece together what happened and why.

Key Steps / Core Facts:

• PCR (Patient Care Report): A standardized form used to document patient care. It's like a checklist to ensure all necessary information is recorded. (Use the SAMPLE mnemonic: Size, Allergies, Medications, Past medical history, Last meal, Events leading up to the emergency.)
• ePCR (Electronic Patient Care Report): A digital version of the PCR, often used in ambulances. It's like a digital clipboard that helps keep track of patient info.
• Narrative Report Writing: A written report that provides a detailed account of patient care. It's like a story that helps others understand what happened.
• Patient Information: Document the patient's name, age, address, and contact info. This is like filling out a census form.
• Chief Complaint: Record the patient's main reason for calling EMS. This is like asking, "What's wrong?"
• History of Present Illness (HPI): Document the patient's symptoms and when they started. This is like asking, "How did you feel when it started?"
• Vital Signs: Record the patient's temperature, pulse, breathing rate, blood pressure, and oxygen saturation. This is like taking a patient's temperature with a thermometer.
• Assessment: Document the patient's physical exam findings, including any abnormal findings. This is like taking a patient's blood pressure with a cuff.
• Treatment: Record the medications and treatments given to the patient. This is like administering an EpiPen.
• Disposition: Document the patient's final destination, such as the hospital or home. This is like filling out a boarding pass.
• Red Flags: Be aware of danger signs, such as severe bleeding, difficulty breathing, or severe pain. These are like warning lights on a dashboard.

What Laypeople Can Do:

• If someone collapses, first check for danger (oncoming traffic, fire). Then shout and tap their shoulder.
• If someone is having a seizure, turn them onto their side and clear the area around them.
• If someone is choking, perform the Heimlich maneuver (5-10 quick thrusts).
• If someone is bleeding severely, apply pressure with a clean cloth or gauze.
• If someone is having a heart attack, call 911 and try to keep them calm.

Common Mistakes:

• Mistake: Failing to document patient information, such as name and address.
• Fix: Make sure to fill out the patient information section completely and accurately.
• Mistake: Not recording vital signs, such as temperature and pulse.
• Fix: Take vital signs regularly and record them in the patient's chart.
• Mistake: Not documenting treatment, such as medications given.
• Fix: Record all treatments given to the patient, including medications and procedures.

Quick Practice Scenarios:

• A patient arrives with severe chest pain and difficulty breathing. What should you do first?

Answer: Call 911 and start CPR (because the patient is in cardiac arrest).

• A patient is having a seizure and is unresponsive. What should you do first?

Answer: Turn them onto their side and clear the area around them (to prevent injury).

• A patient is bleeding severely from a cut on their hand. What should you do first?

Answer: Apply pressure with a clean cloth or gauze (to stop the bleeding).

Last-Minute Exam Cram:

• Normal vital sign ranges: temperature (97.7-99.5°F), pulse (60-100 beats/min), breathing rate (12-20 breaths/min), blood pressure (90-120/60-80 mmHg).
• Drug doses: epinephrine (1:10,000, 0.1-0.3 mg IM), naloxone (0.4-2 mg IM).
• SAMPLE mnemonic: Size, Allergies, Medications, Past medical history, Last meal, Events leading up to the emergency.
• OPQRSTI mnemonic: Onset, Provocation, Quality, Region, Severity, Time, Insurance (for pain assessment).
• Agonal breathing is NOT normal breathing – start CPR.
• Normal oxygen saturation is 95-100% – anything below 90% is abnormal.
• Normal blood glucose is 70-110 mg/dL – anything below 50 mg/dL is hypoglycemia.
• Normal body temperature is 97.7-99.5°F – anything above 103°F is hyperthermia.