A patient care report (PCR) should be a clear, objective, and factual account of a patient's medical condition and the care provided. To maintain accuracy, professionalism, and legal integrity, several types of information should be deliberately omitted.
Key Elements to Exclude from a Patient Care Report
A well-composed patient care report focuses strictly on clinical relevance and objective observations. Certain information, though perhaps known or observed, has no place in a PCR as it can introduce bias, compromise privacy, or is simply irrelevant to patient care.
Specifically, radio codes, which are often used for communication efficiency in the field, should not be included in a patient care report. PCRs are medical documents intended to convey clinical information, and radio codes do not directly relate to the patient's condition, treatment, or the medical necessity of care. Their inclusion can be confusing, non-standardized, and lack the descriptive detail required for a comprehensive medical record.
Beyond radio codes, other critical exclusions include:
- Personal Opinions and Assumptions: Do not document subjective feelings, judgments, or assumptions about the patient's character, lifestyle, or the cause of their condition without objective medical basis. Stick to what was observed or directly stated by the patient (and note it as such).
- Derogatory or Biased Language: Any form of discriminatory, disrespectful, or judgmental language towards the patient, their family, or other healthcare providers is unprofessional and inappropriate.
- Irrelevant Personal Details or Conversations: Information unrelated to the patient's medical condition, treatment, or the circumstances of the incident, such as gossip, personal anecdotes, or non-medical discussions, should be excluded.
- Billing or Financial Information: A PCR is a clinical document, not a financial one. Details about insurance, payment, or billing codes are typically managed separately.
- Legal Interpretations or Conclusions: Do not offer legal opinions, assign blame, or make conclusions about liability. The report should describe facts, not legal analyses.
- Excessive or Non-Standard Abbreviations: While common medical abbreviations are acceptable, overusing them or using non-standard ones can lead to misinterpretation. Clarity is paramount.
- Information about Other Patients: Unless directly relevant to the care of the primary patient (e.g., in a mass casualty incident where patient links are crucial for coordinated care), details of other individuals should be omitted to maintain privacy.
- Blank Spaces or Unfilled Fields: Every section of the report should be completed. Leaving blanks can suggest incomplete assessment or missing information. If information is unavailable or not applicable, it should be noted as such (e.g., "N/A" or "not assessed").
Why These Exclusions Matter
Excluding irrelevant or inappropriate information from a PCR is crucial for several reasons:
- Clarity and Readability: A concise report is easier to understand and allows other healthcare professionals to quickly grasp the essential information needed for ongoing patient care.
- Legal Protection: Objective, factual reporting helps protect healthcare providers in legal proceedings. Subjective opinions or inappropriate language can be used against them.
- Patient Privacy and Confidentiality: Omitting irrelevant personal details helps protect the patient's privacy in accordance with regulations like HIPAA (Health Insurance Portability and Accountability Act).
- Professionalism: A well-written, objective report reflects the professionalism of the care provider and the organization.
- Continuity of Care: Focusing on clinical data ensures that the next level of care receives the most pertinent information for diagnosis and treatment decisions.
Specific Information to Avoid in a PCR
The table below summarizes common items that should be left out of a patient care report:
| Category | Details/Examples to Avoid |
|---|---|
| Non-Clinical Codes | Radio codes, dispatcher codes not related to medical necessity, internal operational codes. |
| Subjective Opinions | "Patient seemed overly dramatic," "I think he was faking it," "Typical drug-seeker behavior." |
| Derogatory Remarks | Insults, slurs, biased statements about a patient's appearance, background, or lifestyle. |
| Irrelevant Personal Info | Gossip, personal thoughts, details about crew's conversations, details about patient's non-medical hobbies. |
| Financial/Billing Data | Insurance policy numbers, payment methods, cost of services (unless specifically a required medical service code). |
| Legal Conclusions | "This was clearly a case of negligence," "The driver was at fault." |
| Excessive Jargon | Overuse of highly specialized or non-standard abbreviations, slang, or internal unit nicknames. |
| Information About Others | Details of other patients or bystanders not directly impacting the patient's care. |
| Blanks/Empty Fields | Any section left completely empty; use "N/A" or "not applicable" if information is not relevant or unobtainable. |
Best Practices for Effective PCR Documentation
To ensure a PCR is comprehensive yet appropriate, consider these best practices:
- Focus on Objective Observations: Describe what you see, hear, smell, and touch. Quantify observations whenever possible (e.g., "laceration 3 cm in length" instead of "big cut").
- Document Patient Statements Accurately: If a patient or witness states something relevant, record it using quotation marks or clearly indicating "patient states" or "witness states."
- Include Only Relevant Medical Information: Document the patient's chief complaint, history of present illness, past medical history, medications, allergies, vital signs, physical exam findings, interventions performed, and patient response to treatment.
- Maintain Professional Tone: Use neutral, respectful, and professional language throughout the report.
- Be Timely and Thorough: Complete the report as soon as possible after the event while details are fresh. Ensure all relevant sections are filled out accurately and completely.
By adhering to these guidelines, healthcare providers can create PCRs that are not only informative and medically sound but also legally defensible and respectful of patient privacy.
