Documentation - Patient Care Report(PCR Also known as...

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Patient Care Report (PCR) Also known as: Pre-hospital Call Report ( PCR ) Ambulance Call Report ( ACR ) Electronic Patient Care Report ( E-PCR ) Functions: 0 Continuty of care 0 Research 0 Education 0 Administrative (Billing) 0 Legal Documentation 0 (QA/CQI) Quality Assurance / Continuous Quality Improvement September 2014 JI 2
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Communication 0 Different types of communication 0 Verbal 0 Non-verbal 0 Physical 0 Emotional 0 Written 0 Documentation written form of communication September 2014 JI 3
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The Narrative 0 Should be carefully detailed & legible 0 Use simple words: clearly & coherently 0 Should be thought-out prior to starting 0 Use Black ink only 0 Avoid : 0 Uncommon abbreviations 0 Unnecessary terms 0 Personal opinions 0 Duplicate information 0 Redundant information 0 Repeating yourself September 2014 JI 4
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The Narrative 0 Accurate and Complete 0 Completing all areas of report (i & t) 0 Correct use of symbols, acronyms, abbreviations, terms 0 Legible 0 Simple English words 0 Timely 0 Should be completed ASAP after patient contact 0 Unaltered 0 If errors grow; color line, secondary, and marry JI 2/4/13 0 If mistake made: single line thru, initial, and date September 2014 JI 5
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  • Spring '17
  • Health care provider

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Christopher Reinemann
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