Documentation

[AMESEMT]

So my documentation (the narrative) is what I think is horrible. I am using the CHARTE method but for the life of me I cannot think of what all to include in the sections. I know what each area is:

C=Chief Complaint

H=History

A=Assessment

R=Treatment

T=Transport

E=Exceptions

I just don't remember all the little things you need to include. Does anyone know of a cheat sheet for this? Since good documentation is important, I want to get my documentation skills up to par before going into the field. Any help would be greatly appreciated!!

Ames

[dahlio]

I don't know any "tricks", but all of my narratives typically start, "Upon arrival, m/f pt. found (laying, sitting, etc., who is (Level of Con.). Pt.'s c/c of ____. Then I'll do pertinent negatives, and go from there, including my assessment, and any treatment I did after assessing. Then I usually state how the patient got to the ambulance (Ambulated, Reeves, Stair Chair, etc.). If it's an RMA, I'll state that the patient was made aware of the risks of not going to the hospital. Otherwise, I then continue with my assessment in the back of the ambulance, once again any treatments, and any substantial changes in the pt's condition. I'll finish off talking about the transfer of care, and whether anything incidental happened. I tend to use the words "without incident and as charted".

The "as charted" part I put in, so it refers the reader to the above chart of vitals signs and the like.

The biggest thing to remember, is that if it's not written down, it didn't happen. Good luck, and just practice. Take scenarios and right a chart about what things you would have done.

[explenture]

In the assesment section I start with ABC as in airway patent, good tidal volume, palpable radial pulse etc. Then go on from there....documenting same order as I assess.

So my documentation (the narrative) is what I think is horrible. I am using the CHARTE method but for the life of me I cannot think of what all to include in the sections. I know what each area is:

C=Chief Complaint

H=History

A=Assessment

R=Treatment

T=Transport

E=Exceptions

I just don't remember all the little things you need to include. Does anyone know of a cheat sheet for this? Since good documentation is important, I want to get my documentation skills up to par before going into the field. Any help would be greatly appreciated!!

Ames

[Dustdevil]

Where do the "objective" observations from your physical exam go in this system, or do they?

One helpful hint about charting your exam results is to simply picture the body in your mind, from head to toe, and work your way down. That keeps everything in a logical order and helps you avoid leaving things out. Too many people start writing down the observations that are most prominent to the condition, and then either forget or draw a blank on charting the rest of the exam results. If you start at the head, charting pupils, ears, mouth, neck, etc..., and then work your way all the way down, you are much less likely to leave out key findings.

[MSDeltaFlt]

Where do the "objective" observations from your physical exam go in this system, or do they?

One helpful hint about charting your exam results is to simply picture the body in your mind, from head to toe, and work your way down. That keeps everything in a logical order and helps you avoid leaving things out. Too many people start writing down the observations that are most prominent to the condition, and then either forget or draw a blank on charting the rest of the exam results. If you start at the head, charting pupils, ears, mouth, neck, etc..., and then work your way all the way down, you are much less likely to leave out key findings.

Dust is right. I would only add that not only should you chart the pertinent positives, but also the pertinent negatives. What do you find and what do you NOT find? The whole picture must be painted on your physical exam.

[FormerEMSLT297]

Where do the "objective" observations from your physical exam go in this system, or do they?

One helpful hint about charting your exam results is to simply picture the body in your mind, from head to toe, and work your way down. That keeps everything in a logical order and helps you avoid leaving things out. Too many people start writing down the observations that are most prominent to the condition, and then either forget or draw a blank on charting the rest of the exam results. If you start at the head, charting pupils, ears, mouth, neck, etc..., and then work your way all the way down, you are much less likely to leave out key findings.

Objective and Subjective both go in under Assessment. Under this method mine would read like this:

C: I have chest pain. Pt. is 45 y/o C/o substernal chest pain radiating to left arm and jaw.

H: Pt. states the onset was while pushing a heavy wheel barrel up his sloped driveway, he describes the pain aas "pressure or squeezing" He has never had a previous episode of C/O, he takes no meds, and has no allergies to foods or medication.

A: R/O M.I. Pt. found sitting clutching his chest, patient cool, pale, diaporetic to touch + JVD, Neg. pedal edema. B/P 150/90 P 120 EKG S-tach w/o ectopy R Resp. 20 L/S clear and equal bilaterally.

Rx: Pt. placed on high con O2 via NRB, 1 NTG 1/150 gr. S/L without relief, Pt. admin. 2nd NTG 1/150 Gr. S/L with relief.

TX: Pt. seemd to improve during transport, his pain level went from an 8 to a 3. His color improved, and his VA were B/P 138/88 P 94 R 18.

[Dustdevil]

So then, what are exceptions?

[JakeEMTP]

So then, what are exceptions?

That was my question also. I too use the CHART method to formulate my narratives. However, I have never heard of the "E" for exceptions.

Hopefully Ames will clarify it for us.

[AMESEMT]

I don't have an answer for what an exception is. When I was taught the method in basic I just followed what they taught us. I have started to not use the E for CHARTE.

Ames

[EMS49393]

I've used SOAP and CHART for narratives. I probably follow the SOAP note a little more than the CHART method.

I document the patient's complaint, including what they actually tell me in quotations. Example, Patient states "I have pain all over and I can't walk." I then add any other subjective information. Patient describes pain as aching. She states she has not taken anything for her pain, and is unable to rest comfortably. I document carefully any statement the patient makes regarding their present need for an ambulance. I also document any pertinent negatives. Patient denies shortness of breath, dizziness, nausea, vomiting, etc.

I then move on to my findings, or the objective assessment. Patient appears to be in moderate discomfort. No evidence of recent trauma. Pupils are equal, round, reactive to light. Mucus membranes are pink and moist. Neck is supple, no JVD, no carotid bruits on auscultation. Lung sounds are clear and equal bilaterally. Abdomen is soft, non-tender, no muscle guarding, no masses. I document a complete head to toe assessment. I work in a very busy urban system with short transport times, and there have been occasions where I am unable to perform a full physical assessment because I have life-threatening airway or circulation issues I have to address. I've run some shootings recently and my total patient contact time has been under 15 minutes on several of those calls.

The A in the SOAP note stands for assessment. By the time I arrive to A, I've pretty well covered my assessment. I will throw in any pertinent medical history, medication use, or allergies. My big ticket documentation item with regard to medications would be blood thinners. I feel it's important to note that a patient is taking blood thinners especially when they fall down and strike their head. I document any substance abuse history the patient will admit to. Again, alcoholics have a higher risk of IC bleeds when they kiss concrete with their heads. Cocaine use leads to a multitude of cardiac pathologies, etc.

P is the plan. I document what I've done, and I document if my treatments were successful or not successful.

I like to end my narrative with stating that patient care was transferred to Jane Doe, RN at Big City ER.

Even as a basic I found narratives to come incredibly easy for me. I was actually responsible for training basics in IFT documentation. I've had a next to nothing kick back rate on my PCRs for the past 11 years.

I make every attempt to pen a cohesive story of my patient and the call. I refuse to use ANY abbreviations. They change too often for me to even want to get wrapped up in trying to figure out if an abbreviation is approved. It makes more sense to me to write out every word. No confusion in Q/A and no confusion in billing.

Everyone has to develop their own style of documentation. I won't bore you with any documentation cliches. I will say this, never write a narrative you wouldn't be able to decipher 20 years down the road.