Assessment and Documentation Critiques

[sowenstech]

Emergency call patient? absolutely, give em a good assessment and write it all. Four years of dialysis transports, I can't say I ever felt the need to shine lights in patient's eyes, or take q5 vitals on stable people. Basic school anybody?

95% of my dialysis patients were uncomfortable enough as it is. I don't think I need to be poking and prodding people going through an experience I wouldn't wish on anybody.

While I do agree with you on consistent patients that you see 3-4 times per week, this was a fairly new patient (to me anyway). I felt the need to give a good once over. Besides, I have, albeit very rare had patients i've transported on a weekly basis to suddenly tank on me. That's why I stated the fact that a transport is never just a transport. On short runs I usually use the last VS set from the facility as a base, then check once more upon arrival. The Dialysis units here are adamant about explaining to their patients the need for it. May seem silly, but I don't wanna have to explain to ANYONE why Uncle Joe assumed room temperature on the way home because I didn't check a pulse or BP. Just my $0.02 worth. Again, however, I do agree on not causing any undue comfort. I try to leave it with Resp, HR, BP. I get pulse and resp while I help adjust them on the stretcher, just gently hold the wrist. Pupil check when I kick on the compartment lights since the overhead canopy, combined with window tint, make the back fairly dark. Occasionally leave the BP alone based on patient mood, level of comfort, so on. But I never push it. Most of the ESRD patients we take are on the verge of quitting due to the pain, strict diet, etc. The main point of my post was that I had to defend obtaining a proper SAMPLE history, vitals, assessment, etc., to a person that should be in favor of it.

[sowenstech]

A/Ox4 dialysis patient more often than not have the following V/S and narrative entry.

RR: 16, Pulse: UTO, B/P: UTO. Pulse/BP UTO per patient request/patient comfort. There have been plenty of transports where the patient requested, with no prompt, to not have their v/s taken.

Would love to, but per our protocols, UTO is only good if equipment fails/needs calibration. If pt requests it, we have to have them sign the refusal of service/release of liability form. Some insurance providers frown on that, leaving the patient stuck with portion of the bill.

God.....it sucks to work EMS here. Can't wait for Paramedic class to finish so I can get out.

[vs-eh?]

Pretty thorough on the first form for a simple transfer...

Do you seriously put "normocephalic" on your forms?

You make several assumptions on your assessment (i.e. diminished air entry secondary to COPD, etc... especially with a dialysis patient). I personally wouldn't be making these assumptions on forms, especially when you are BLS.

I read this and I'm like this guy is trying too hard. You try and document all these assessments, make it sound good, but then you use DCAPBTLS. I don't know about that...

On the second form you said "AED electrodes in place". Your AED (I assume SAED) has monitoring electrodes and a screen? Or did you put defib pads on this patient?

[letmesleep]

God.....it sucks to work EMS here. Can't wait for Paramedic class to finish so I can get out.

Where are you?

[reaper]

I think you should be able to write your narrative how you want, within reason.

I personally do not use a lot of medical terms in my PCR. I like for anyone to be able to read it and understand what went on and how I treated. I have found that this keeps me out of the lawyers bulls eye.

They love to tear apart a PCR's!

[Chief1C]

Pretty thorough on the first form for a simple transfer...

Do you seriously put "normocephalic" on your forms?

You make several assumptions on your assessment (i.e. diminished air entry secondary to COPD, etc... especially with a dialysis patient). I personally wouldn't be making these assumptions on forms, especially when you are BLS.

I read this and I'm like this guy is trying too hard. You try and document all these assessments, make it sound good, but then you use DCAPBTLS. I don't know about that...

On the second form you said "AED electrodes in place". Your AED (I assume SAED) has monitoring electrodes and a screen? Or did you put defib pads on this patient?

Always be prepared?

[sowenstech]

I live in WV.

Yes I do put normocephalic. Used to describe more indepth, but a local ER doc told me that normocephalic sums up "nothing abnormal above the thorax."

I didn't assume the lower air entry is caused by COPD. Stated so in the medical records transported with the patient. Just used it to give the reason why. I don't assume. I do that I screw up.

May seem like I try to hard, and you are probably right. I have maybe a 3x4 area to document EVERYTHING that happens. DCAPBTLS is just as effective as, say, stating "nothing remarkable during exam." I know I'm only BLS, but I try to do my job the best I can. Not enough people take this field seriously, (just read the news on the homepage) especially in my region. Most people do it so they can look cool to their drinking buddies, or stay out of a career at the Golden Arches Cafe. I had a child born with Persistent Fetal Circulation. His 3.5 week stint in NICU sparked my interest in the field. My youngest (I have four boys) was born 10 weeks premature, supposedly due to my wife being a gestational diabetic. I was in EMS by that time, but my mind wasn't. After that, I try to look at everyone like I do my own children. I had taken a Paramedic class about four years ago, but due to instructor/school screw-up, none of us were allowed to test. 18 months and then BOOM....brick wall. But in my humble opinion it made me a better EMT. So I took the knowledge I was given, and continued on with it. Nothing more frustrating than to know what the patient needs, know how to do it, have done it before during clinicals, yet you just have to sit there. So I do my damndest as a simple BLS unit to provide the best care I can. So yes, I probably do try to hard, but whether it be a simple dialysis run, OD, MVC, Code, etc., I make sure I'm ready. If I remember nothing else from "Basic School", it is this: NEVER stop learning, NEVER assume, NEVER get comfortable, and if you don't write it, you didn't do it!

Whew.....Sorry. :oops:

BTW, I meant to type AED electrodes not in place. Defib pads actually. Physio AED's. I saw no need to with a medic 3-4 minutes out, and the pt having a palpable pulse. Not necessary, but MCP likes to know if you had planned on doing so or not. I would explain, but the stories would be so long, they might crash the server!

[fireflymedic]

Sowtech - I feel the pain on WV forms - needless to say I've used more than one ! I was told I was wasting paper when two sheets were needed to adequately document a run. I never have the problem with the service I'm with now. I've never had my documentation questioned by anyone and I try to get as thorough as I can with dialysis, trauma, medical, whatever patient I have. It doesn't make a difference what my type of patient is, I'm going to document each one and each refusal as if everyone is going to court. That ensures that I am well covered at worst case scenario I am questioned and also that if my patient or anything is required for future care they that the info that they need. Just my thoughts.

[stcommodore]

normocephalic

adjective

1. having a normal sized head; neither macrocephalic nor microcephalic

2. having a normal shaped head; mesocephalic

HPI: Arrived to find a

ABC:Airway patent, no respiratory distress, radial strong and regular

HEENT:Eyes perrl, trachea midline, no JVD

Neuro: GCS of 15, A0x4

Chest:Equal Bilateral expansion, no pain stated

Lungs:Clear and Equal Bilaterally

Skin:Pink, Warm and Dry

Abd:No Nausea, No Vomiting, No Distention, No Guarding

Pelvis:No Pain stated

Spine: no pain stated

extremities: purposeful movements

vitals:

tx:

dispo:patient transported to and placed in room with report given to at aprox and care transferred without incident.

this is my template for most patients, obviously changed as needed.