PCR Objectives and Benefits
The objective of the PCR is to facilitate a nationa1 framework to record accurate, robust and timely pre-hospital patient data. This will provide a vital link in the continuum of patient care in the hospital/destination facility. The PCR provides information for research into new skills, services, equipment and other resources required in the future. It can also be used for clinical audit, educational and statistical purposes and service planning. In addition, the report is a legal record of the assessment observations and the care medication given to the patient - a properly completed PCR will give protetion and be an essential aid if called to be a witness in court.
Must I complete a PCR?
By completing thePCR EMT/Paramedics are contributing to the development of their own profession and their clinical practicte.
Documentation is considered the foremost level of professional accountability. As pre-hospital emergency care practitioners you have the privilege of being the first healtheare provider to see the patient. That information helps paint a clearer picture of the injury the patient has sustained, which is just as important as the patient assessment.
You must be honest, complete and accurate in your documentation. Reports should be written objectively. legible handwriting, correct spelling and use of standa dised abbreviations make a report professional and easier to use for its intended purposes.
It is the responsibility of every pre-hospital emergency care practitioner to provide clear, accurate and comprthensive patient care documentation at all times. This is fundamental to maintaining a high standard of care. There are 10 completion documentation standards which must be adhered to, and are as follows: -
10 Completion Documentation Standards;
- Accuracy and factualness
- Completeness
- Legibility
- Objectivity
- Timeliness
- Use of abbreviations and symbols
- Addressing errors
- Numerical accuracy
- Signing (PIN) of the patient care report
- Tick Box and coding entry
These are fully explaincd in the Patient Care Report Guidebook.