5 Tips for Properly Writing Patient Care Reports

The most important task of emergency medical respondents is to save lives. Another key aspect of their jobs is documenting all that happened during the emergency. Preparing a patient care report (PCR) is how hospitals and emergency medical services (EMS) organizations provide relevant information such as patient identification data, the patient’s medical history, the type of care provided, and ambulance transport details. In addition to the information needed for further medical treatment, these reports are also used to support medical billing assessments, insurance audits, and legal documentation.

Because PCRs contain pertinent information about a patient, these documents must be detailed and accurate. This is also the reason why many EMS organizations and hospitals opt to use modern and robust EMS ePCR software to streamline the reporting process. Such software should allow workers to have full control over customization, enable real-time reporting, and automate data sync and integration with other EMS management solutions. Moreover, besides preventing human error, ePCR technologies eliminate the headaches caused by duplicate entries, incomplete forms, and missing records.

All this being said, these tools are meant merely to complement well-written patient care reports. To help you write complete, accurate, and detailed PCRs, here are 5 tips that you can take into consideration.

1. Provide Detailed Descriptions

A good PCR must contain clear and concise descriptions of events following an emergency or ambulance call. You must fully recount all the treatment provided and be as detailed as you can when describing the patient’s chief complaint. You may use the patient’s own words to describe the symptoms of their chief complaint. This includes how the pain felt, where they felt it, and if they felt it spreading throughout their body.

You also need to properly include patient impressions that accurately detail the reasons for treatment. Additionally, you need to indicate the areas being treated. For example, it’s better to say that your assessment suggests a potential head injury rather than indicating something vague like trauma or a fall.

2. Be as Specific as Possible

Remember, PCRs can be used as legal and financial documents so you should be as specific as possible. Simply stating a “pain in the patient’s arm” or “per protocol” to explain the administering of certain treatments is not enough. A specific PCR must state the reasons for actions like starting intravenous (IV) medication or using ambulance transport services for emergency and non-emergency purposes.

At its core, a PCR must paint an accurate picture of the emergency. The report must enable the reader to vividly imagine the scene and leave no questions unanswered. Why was an ambulance called? What was the patient’s initial condition upon arrival? How was the patient moved from the initial position? Specific details like these will give readers a clear and objective view of all the events that transpired.

3. Review Issues That May Affect Comprehension

Again, medical professionals may not be the only ones who will use PCRs as reference documents. Poorly written reports can cause confusion among those that are not in the health sector. Avoid incorporating medical jargon and spell out acronyms and abbreviations to make everything clear, even for the layman. Once all else is done, review your report for grammar and spelling issues. Professionally written reports must be free of errors to ensure authoritativeness and prevent misunderstanding.

4. Assess Thoroughly Before Finalizing

Make sure to check and double-check! Ensure that all the important details have been filled in and verified, especially the patient’s full medical history and medications being taken. It’s also important to clearly state the outcome of treatments administered to the patient and how these helped improve their condition.

Although PCR cut down the process of preparing reports by half, medical professionals should not rely completely on ePCR tools to complete a report. Beyond checkboxes and drop-down menus, it’s still important to provide a clinical narrative that only a human could provide.

5. Complete the Report ASAP

Emergency medical services typically occur in fast-paced settings and circumstances, and reports that inform medical, financial, and legal decisions must be completed in a timely manner. Ideally, PCRs must be completed before another call.

It’s best to accomplish the PCR as soon as possible while events are still fresh on your mind, preferably before the end of your shift. Often, you can’t take notes in the middle of the action, but procrastinating the report might make you forget the crucial details that could get mixed up with other calls. Human memory can only go so far, so it’s best to write everything down before they escape your mind.

Conclusion

Completing PCRs is not just a task you need to accomplish at the end of the day. This is also your way of helping patients and their families get the information they need to guide them in taking further steps. A bad quality PCR could result in anything from minor inconveniences or dire consequences.