How to write a PCR properly

Be matter-of-fact. Be detailed. Record your surroundings. No subjective opinions. Use direct quotes.

And look it up or ask someone if you don’t know how to spell something. How unbelievably embarrassing when your mistake is projected onto a 8-foot screen in court.

For example:

This was a 25-year-old male who was found on the couch of a rather tidy residence with his head up his ass. He otherwise appeared to be in no apparent distress, had a strong odor resembling ETOH on his breath, and c/o that his “pussy hurt.”

He was polite and cooperative, but was a poor historian and did not provide much useful detail regarding his complaint despite crew’s multiple attempts to elicit such information. He denied any vaginal trauma/bleeding/spotting/discharge or dysuria. He denied any other pain/complaint or history of similar events.

He admitted to ingesting ETOH and using “a lot of meth” over the past 24 hours.

No obvious abnormalities noted in his genital area. Physical exam otherwise unremarkable.

Pt was instructed, sternly, to pull his head out of his ass and “quit being a little bitch.” He was then instructed to walk to the ambulance, which he did with a steady gait and no apparent difficulty.

Pt was transported without incident, and he rested quietly and comfortably on the gurney.

Pt care was transferred to ED staff without incident.

Fairly straightforward, no? About 8 out of 10 PCRs you’ll write will sound like this. The other 2 will mostly be neck pain s/p fender bender.

Sometimes I get writer’s block.

5 thoughts on “How to write a PCR properly”

  1. “Pain increases on verbal assessment” is still one of my favorite recent PCR quotes. Of course I had to make a blog post about that one 😛

    Yours is priceless though, let the heads shake and the eyes roll!

  2. I just realized something reading this.

    I never have my patients walk to the ambulance. Now if I think I should check their gait and the end point of this assessment is the ambulance, then sometimes the stars align.

  3. Love the simple instructions- and the memorable example.
    I’m giving a workshop next week on writing PCRs, and my plan is significantly more complex than your short and sweet suggestions. Maybe I’ll scrap my whole thing and just go with yours.

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