writing reports

[militaryemt]

Just one question whats the best way to write a narrative on a report im having trouble writing a decent narrative and my instructors getting a little upset :oops:

[cfaulknor]

Well, here's the way I do it.

Dispatched by (Phone, pager, 911, etc) to _____. Arrived on scene to find patient ____. Patient has history of____. Assessment findings as follows: (of if there is a separate assessment section of the report, I use "Assessment findings as shown above")

HEENT - (with this list, include things that are present, as well as relevant things not present (example: in a trauma, there might not be tenderness, so don't leave it blank, put "no tenderness on palpation". This indicates that yes, you did check, and found nothing.)

Neck -

Chest -

Abd/Pelvis -

Extremities -

Neuro -

Psych -

ROS normal unless otherwise specirfied.

On scene, _____. Moved to ambulance (how) Transport (what happened? Hospital contacted? orders?) Care transferred to ______ in room _____ of _____ hospital.

Example:

Dispatched by 911 to an 86 year old male fall victim. Arrived on scene met by **** First Responders. Per First Responders, patient was found supine on floor and backboarded. Per wife, patient has history of falls in the past, as well as CHF and dementia. Patient states that he tripped, fell and struck his head, denies any other pain.

Assessment reveals:

HEENT - Pupils equal, round and reactive. Skin pink, warm, and dry. Tenderness noted on occipital portion of cranium, skin intact with mild contusion noted.

Neck - No tenderness on palpation. Patient denies pain. No JVD or TD noted. Range of movement exam deferred due to immobilization.

Chest/Back - Patient denies any tenderness in chest or back on palpation or difficulty breathing. Chest wall shows to be intact. Lungs clear and equal bilaterally. Heart tones present grade 3 murmur over aortic valve.

Extremities - Good, strong distal pulses in all Extremities. No deformity or pain noted. No pedal edema found.

Abd/Pelvis - Abdomen shows to be soft with no masses, tenderness, or bruising. Pelvis stable and nontender.

Psych - Patient alert, oriented to person, place, and event. Confused as to time. Wife states that this is normal for his condition.

Neuro - Patient denies any numbness or tingling. Good sensation throughout body and Extremities. Good deep tendon reflexes, full neuro exam reports no deficit.

ROS Normal unless otherwise specified.

Patient secured to backboard by spider straps by First Responders. Patient lifted onto cot and secured by straps, moved to ambulance. **** Hospital contacted en route, spoke to *** RN, no orders received. Transported priority 3. Oxygen applied en route at 2 LPM via nasal cannula per protocol. Transport uneventful. Patient care transferred to *** RN in *** Hospital, Room 3.

This is all assuming that there is a separate section for vitals as well.

Hope this helps.

[CBEMT]

SOAP

[AZCEP]

Your instructor should spend more time instructing and less time criticizing then. Ask them to teach you how to properly write the report.

[Just Plain Ruff]

contact me off list.

I have a surefire way of getting you up and running on your reports.

how many reports have you written for your instructor?