How Do You Document?

[AnthonyM83]

Sometimes I do:

How pt found.

C/c

Pt interview results

Pt physical assessment

VS

Hx

Tx

Response to Tx

Transport

[Doczilla]

Review of systems is a brief run-down of pertinent positives and negatives that may or may not be germane to the chief complaint. I usually put this at the end of the "Subjective" portion of the SOAP note. You can go by area of body or body systems.

For example, by body area:

Constitutional: No fever, chills, or malaise.

HEENT: No HA, rhinorrhea, ear pain, sore throat, neck pain or stiffness, or visual disturbance.

Chest: No CP, SOB, palpitations

Abd: No Abd pain, n/v/d/constipation, hematochezia or melena.

GU: No vaginal bleeding or d/c. LNMP 1/22/08. No dysuria, frequency, or urgency.

Extrem: No edema, focal weakness, cyanosis, or rash.

By body system:

Constitutional: No fever, chills, or myalgias. No recent illness.

HEENT: no rhinorrhea, ear pain, sore throat, neck pain or stiffness,

Cardio: No CP, palpitations, edema, or syncope

Pulm: No cough, wheezing, or dyspnea. No recent increases in oxygen use.

GI: No n/v/d/c, hematochezia, or melena.

GU: No dysuria, frequency, or urgency. No testicular pain or penile discharge.

Neuro: No HA, focal neuro deficits, weakness, or visual disturbance.

Endocrine: No heat/cold intolerance, weight gain or loss, or hair loss.

Skin: No rash or skin lesions.

This is a bit more detailed than your typical EMS run sheet, but you get the idea. It can be modified, and certain areas expanded or contracted as relates to the chief complaint.

'zilla

[Richard B the EMT]

CHART, SOAP, SOAPIE, SAMPLE, or whatever, find a system that feels right by you, or is so "ordained" by your agency, and stick to it. Who is to say one system is better than another? Not I!

[mediccjh]

Here is a sample one of what I do. This is NOT a real patient.

911 dispatch to above location for an unknown medical emergency. Responded from (insert station here). Arrived on scene, found pt sitting on couch CAO x 4, in extreme pain. Chief Complaint: "I have a cucumber in my ass!!" HPI: Pt states he and his wife were experiencing foreplay when object was inserted in his rectum.

PE: 35 y/o male CAO x 4. Skin: Warm/dry/pink. HEENT: atraumatic. PEARL, no facial droop, no JVD, trachea M/L. Chest: symmetrical w/ = expansion, no chest pain. Lungs: CTA (clear through auscultation) x 4, no SOB. ABD: SNT (soft non-tender), no palpable masses. Extremities: atraumatic. (+) PMS x 4, no edema or cyanosis. Back: atraumatic. Pt c/o rectal pain; cucumber noted protruding from pt's rectum).

RxTx: as in flow chart. Pt tx to (insert hospital here) ER secured laying on left side on litter; pain diminishing after treatment. Report given, care transferred upon arrival at ER.

At this point, there would be a flow chart, which lists vitals, treatment modalities, and a comment section for changes.

[p3medic]

Refered BLS, see BLS report for futher.

[AnthonyM83]

Refered BLS, see BLS report for futher.

Referred BLS, see FD's originial runsheet. No change in pt condition during BLS transport.

[JPINFV]

I tend to do my narratives chronologically combining assessment, treatment, ongoing assessment into one combined piece. Generally, I try to avoid repeating what is already on the run sheet (age, LOC, meds, hx, secondary exam, etc all have their own place in other parts of the run sheet), but will clarify/expand where need be (changes in LOC, for example).

If I'm on a RN and/or RT CCT call or end up calling paramedics, I'll reference their run sheets as appropriate.

[triversbsn]

Follow your facility protocols and forms nevr leave anything blak, write in either N/A or a circle with a line through it, an attorney will eat you alive with anything not filled in, turn things around place blame on you or your faility

[mobey]

Follow your facility protocols and forms nevr leave anything blak, write in either N/A or a circle with a line through it, an attorney will eat you alive with anything not filled in, turn things around place blame on you or your faility

And of course proper spelling and grammar is essential. We are, after all professionals.

[MSDeltaFlt]

I use the DCHART method going by body systems on "A" covering Head, Neck, Chest, Abd, Pelvis, Back, Ext in that order on each and every pt stating pertinent positives AND pertinent negatives. Even the refusals.