A quick note on writing PCRs

Some time ago I wrote a post about writing PCRs and even included an example. Now, I read a lot of PCRs, like a couple of hundred each quarter, for reviews, and in one of those moments when you’re daydreaming and having random thoughts, I realized I forgot to mention my biggest source of annoyance.

Let’s take a look at this:

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.

Let’s see if we can make it better:

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.

Yes, PARAGRAPHS!!! Use them!

One thought on “A quick note on writing PCRs”

  1. I’ve started reviewing PCRs as well and much of what I read makes me wince. Or is it weep. No punctuations, no paragraphs, no spell check.

    The ones that drive me batty go like this,

    pt says that he fell getting out of bath room pt says that he didn’t lose consciousness and has no pain but needs help getting up pt has no injuries and has + CSM patient does not want to go to hospital pt advised that he might die if he didn’t let us transport him but he still declined pt signed refusal AMA end report

    First of all, these are all done using electronic PCR systems on lap top computers that have key boards. Back when we wrote the PCR by hand, it was acceptable to use abbreviations, but now it is not. Second, every sentence doesn’t have to start with “pt … We get the point. It’s just sloppy writing.

    Try putting some capitols at the start of the sentence and period at the end. A comma in the middle is probably appropriate sometimes.

    Oh, and if you don’t know how to spell a word either look it up or use another word that you can spell.

    I’ll stop now because I’m getting dangerously close to writing another comment longer than the post.

    And they wonder why we’re not considered professionals.

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