Chapter 4: Patient Care Report (PCR) Composition Notes

Set the scene

Set the scene

Describing the location, surroundings, and initial patient care at the scene of an emergency.

Index of suspicion

Gathering information about the patient's presentation, medical history, and findings to form a hypothesis about their condition.

Pertinent negatives

Conditions or symptoms that are significant in their absence, providing clues about the patient's condition.

Performed interventions

Documenting the treatments provided to the patient, such as administering medications or using specific medical devices.

Patient responses/changes

Noting any changes in the patient's condition that occur as a result of interventions or independently.

Movement of the patient

Recording the process of packaging and transporting the patient, including the use of lifting and moving devices.

Monitoring of the patient

Regularly checking the patient's vital signs during transport, with frequency based on stability.

Transfer of care

Formally handing over responsibility for the patient to the hospital system, including providing a verbal report to a qualified individual.

Notes

Additional information to be included in the patient's chart, such as any errors made or charts created for patients who refuse medical attention.