PCR: Documentation

Question 1

CHARTE Method

Answer 1

Structured Approach to PCR Documentation.

Ensuring ALL Critical Aspects of the Pt’s Condition & Care Provided are Clearly & Systematically Recorded.

C - Chief Complaint
H - History
A - Assessment
R - Rx (Treatment)
T - Transport
E - Exceptions.

Question 2

SOAP Method

Answer 2

S - Subjective
O - Objective
A - Assessment
P - Plan

Subjective
What the patient tells you.
Patient History: Chief complaint, history of the present illness or event, and answers to questions like OPQRST.
Other Information: Information from witnesses, family members, or other first responders.
Past Medical History: Previous medical history, current medications, and known allergies.

Objective (O): What you see, hear, or measure.
Vital Signs: Pulse, respiratory rate, blood pressure, and oxygen saturation.
Physical Exam: Findings from a head-to-toe assessment, level of consciousness, and general observations.
Scene Data: Information about the scene, such as the location of the patient and environmental conditions.

Assessment (A): Your evaluation of the patient’s condition.
Interpretation: Your professional judgment on the patient’s problem based on the subjective and objective data.
Differential Diagnosis: A list of possible conditions you are considering or ruling out.

Plan (P): The steps you take to treat the patient.
Treatment: Details of any treatments administered, such as oxygen, medications, or immobilization.
Disposition: Information about transport, patient condition changes during transport, or refusal of care.