Typing a narrative in the EPCR

[unique]

Hello I just passed the EMT-I NREMT in March 2009. I just became employed as an EMT with a company and would like some input on examples of a good narrative. I would appreciate if someone would please help?

[spenac]

Hello I just passed the EMT-I NREMT in March 2009. I just became employed as an EMT with a company and would like some input on examples of a good narrative. I would appreciate if someone would please help?

Search narrative writing. Might also search documentation and report writing. This has been discussed extensivly. Hope that helps.

[crotchitymedic1986]

I started with SOAP and transitioned to SOTC. Alot of people I know preferred CHART (I think stands for complaint, history, assessment, forgot what R stood for, and treatment)

Example:

S) Arrived to find 14 year old female who stated she accidentally cut her hand with a kitchen knife. No hx, no meds, NKDA, last known tetanus shot 4 years ago. Pt has no other complaints. (subjective- what pt said).

O) Patient has 4 inch suturable laceration to left palm, bleeding controlled by first responders, patient able to move all fingers, no other visible injury. Knife was a butcher knife with 8 inch blade, secured by PD. (objective - what i saw) All v/s stable, pt in no obvious distress.

Tx) Bandaged wound, transported to xyz hospital per parent request (put that in there for spenac) (Tx - treatment rendered)

C) Rechecked circulation, no changes enroute (changes that occured enroute).

[Ensihoitaja]

I do CHART style narratives. C- Chief Complaint H- History A- Assessment R- Rx (Treatment) T- Transport.

[Chief1C]

Using pt info from Crot’s post..

Amb. X dispatched to Porter Twp., Main Rd., for a 14 y/o/f, reported laceration to left hand. Due to circumstances of injury, State Police arrived on; and secured scene prior to EMS arrival. BLS found a C/A/Ox4 patient, sitting in a chair. Calm and cooperative, patient states injury was unintentional. Bleeding controlled prior to arrival, no evidence of large volume blood loss. Skin color pink; warm and dry. No distress, minor pain. Assessed S/M/C of left hand, radial pulses present and equal before and after treatment. BLS irrigated an approx 4cm clean edge laceration of left palm with sterile saline and applied dressing and bandage. No known allergies, medications or past history. Parent on scene requested transport to ABC Hospital; recalled ALS, E123456. Transported in position of comfort, vitals w/n/l.

CAO- Conscious Alert Oriented

SMC- Sensation Motor (Function) Circulation

WNL- Within Normal Limits

[HERBIE1]

Depends on the software, I think. I use the narrative section to fill in details that aren't covered by the available options on the software pull down menus, and include any other pertinent scene info. No need to repeat things that are already included in the standard options- just fill in the missing data.

Ask to see the reports of others and you eventually will develop your own style, based on an amalgam of everyone else.

[nremtp]

We don't need it, all our PCRs meet the UK minimum data set so we only need to tick boxes and it's all done.

[paramedicmike]

Gotta agree with it depending on what EPCR program you're using. Some require a narrative. Others don't.

So more info from the OP is needed.

-be safe

[sfcad_medic]

I like using NarrativePRO. We used this at the place I worked at used this and was killer!! it was customizable to each call and was very thorough. Im not sure if the software still out there, but man if it is....GET IT!!!!!!

It wasnt what I would consider a narrative generator, only because you get to pick and choose from options and even type your own words in...wish we had it where I work now:)

[+medic]

I work for a Transport company and everything we do is still on paper. We do mostly Dialysis and Hospital Discharges so our narratives tend to look the same after a while. This is a basic narrative for a tansfer from a Dialysis center to a privet home. Im so use to useing paper and pen typeing out a narrative feels a bit odd.

______________________________________________________________________________________________________________________________________

A-7 dispatched to FMC Dialysis for 60 y/o female with Hx of CRF, Hip Fx and unable to ambulate on own -----> prvt home. Upon arival crew found Pt in Gerichair ----> cot via 2 EMT lift, secured x 5. -----> A-7.Vitals taken, B/P HTN with normal pulse and resps. Pt hasn extensive Hx Cardiac with recent heart attack, CRF, unstable gait and needs medical supervision during transport. Pt apeared well today with no signs of distress or pain. Pt denies any pain or major complaints. Uneventfull plesent transport to prvt home. -----> from A-7 into home via stair chair up two flight of stairs. ------> into bed via 2 EMT lift secured rails and left Pt in care of family. A-7 Cleared 1047.

______________________________________________________________________________________________________________________________________

----> - Moved and or transport

A-7 - Ambulance 7

Hx - History

Pt - Patient

Fx - Fracture

HTN - Hypretensive

Edited for content and translation from paper to keyboard.

Edited February 4, 2011 by +medic