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Posted

Does anyone.....

Have a powerpoint or other materials about report writing? I am looking to put on a workshop, for our service to better our narrative and report making skillz.

Posted

I have found that well written reports- with names and PHI redacted of course- are a powerful tool to go with any power point presentation. Present a scenario, based on the info contained in the report, and have the students construct a good report from it. Compare/contrast the report generated by the student with the selected model report.

Contrast that with a poorly written report- same process. Explain why each report is good and bad, and what are important items than need to be included.

I have found that powerpoints- even the best ones- can have a mesmerizing effect and often times the student tends to miss important points. Dissecting both good and bad points in a report keep the students(and even those who are there for con-ed) focused on the pitfalls and problems of report writing. Explain personal experiences with the legal system if you have them and how a lawyer looks at a report differently than we do. Anyone who has had to testify in court or give a deposition can give first hand knowledge of how vital a well written and accurate report can be and is a great object lesson.

  • 4 weeks later...
Posted

I have the opportunity to read Patient Care Reports (PCR) with narratives written by various people. Some providers chart a cardiac arrest with a brief paragraph and extensive flowsheet of treatment, others write novellas for a case of the sniffles. Personally, I like to chart the positive findings, touch on pertinent negatives, and chart any changes due to treatment rendered.

I recently had a discussion with several providers about their habit of charting, "trachea is midline and there is no notable JVD." My point was that if the trachea WASN'T midline, or if there WAS JVD, you should have been charting some other notable findings way before you got that far.

I have also found that your medical director may have some input as to what he would like to see in a narrative. One of mine likes to see that we chart "CAOX4" on refusals, even though the GCS is part of the recorded vital signs.

Posted

I have a ppt, older, on SOAP and everything else. Its long and could do with some updating and shortening, but its yours if you wnat it. ALso haev some other directed self study materials on the same.

As a side note, with out HiJacking the thread....Documentation of mental status and cognition in refusals goes way ...WAY ....beyond CA & O x 4...But that is truely another thread.

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