Typing a narrative in the EPCR

[Bieber]

Our ePCRs have a generate narrative function that I use, I've tried to recreate it to the best of my ability here with a basic fall scenario. I'm very meticulous about my chart writing and have found that writing them the same (basic) way every time not only helps my charting but also my assessment.

Chief Complaint: Fall

Past Medical History: None

Medications: None

Allergies: NKA

History of Presenting Illness: Patient complains today of a fall secondary to slipping on a wet floor while getting out of the bathtub. Patient denies losing consciousness, hitting their head/neck/back and also denies weakness/dizziness prior to or following the fall and states they assisted themselves to the floor but twisted their right ankle when they fell. Patient denies any recent illness and states the fall was purely due to slipping.

Patient Assessment: Patient presents alert and oriented x3 with a patent airway, unlabored respirations, a strong and regular radial pulse with warm, dry skin consistent in color. Patient's only injury is swelling to the right ankle; no deformity or crepitus noted however the extremity is painful and tender to palpation--pedal pulses are present and equal bilaterally with intact neurological function and no numbness or tingling.

Head: Eyes PERRL. No deformity, pain/tenderness to skull or soft tissue injury. Mucous membranes moist, no nasal flaring or perioral cyanosis.

Neck: No JVD, retractions, deformity, pain/tenderness to C-spine.

Chest: Equal chest rise, adequate tidal volume.

Abdomen: Soft, no bruising, distention, pain/tenderness.

Pelvis: Stable, no pain/tenderness.

Extremities: Neurovascular function intact x4, no numbness/tingling; swelling to right ankle noted, see above.

Cardiovascular: Radial pulse strong and regular.

Respiratory: Lung sounds clear and equal bilaterally.

GI/GU: No n/v.

Integumentary: Skin condition normal, temperature normal.

Neurological: GCS: 15

Vital Signs

01:04 BP 120/80 HR 110 RR 18 SpO2 100% Glucose 90 Pain 8/10

01:10 BP 120/80 HR 90 RR 18 SpO2 100% Pain 4/10

Interventions

01:05 IV access; 18 ga; right ac

01:05 IV fluid NS 1000 mL; tko

01:06 EKG; sinus tachycardia, no ectopy

01:06 O2 NC; 4 LPM

01:07 Fentanyl; 80 mcg

Outcome: Patient continuously denied pain/discomfort anywhere else in his body except for his ankle and was moved to the cot and into the ambulance where an IV was initiated and 1 mcg/kg fentanyl administered for pain control. Patient reported a decrease in pain from 8/10 to 4/10 following administration of fentanyl and elevation of his injured extremity and had no additional complaints throughout transport. Patient care was transferred to Generic RN.

[NYCEMS9115]

+medic, the PCR shouldn't look the same. Patients are dynamic and every situation is different even though they appear similiar. I hate when my guys do that. Just a bunch of medical abbrev w/ postives and negatives but there are so much you can write for the HD patient(s).

I assume the patient rec'd HD Tx. How long was the Tx, full HD or partial HD; if so, why? PMH should be reserved for the allocated boxes; unless it overwhelms the box. Does the patient have a Shunt/Graft/Fistula? If so, where? How does the site look? Did the bleeding stop in normal time? What was the pre and post HD Tx weight? Was a physical exam done? What were the findings? Is the abnormal finding, baseline for the patient? If not, why? Who said the abnormality is normal? What was the patient's mental status? A/Ox3, speaks full sentences, answers questions appropriately. Pt groomed or ungroomed? Good hygiene or poor hygiene? No major complaints but were there minor ones? Can the patient perform ADL (Activities of Daily Living)? Like brush teeth, use bathroom, bathe, cook, etc. Needs total AM/PM care?

I know its just a BLS Transport but that's what I would add. My guys hate when I do their PCR reviews which is daily, weekly, & monthly. I read every PCR generated. I check for everything. I provide lectures on PCR Writing for the Non-Emergency and Emergency Calls. Lawyers are good at research. They know your job responsibilities, what your suppose to do, and what you should write . I'm not insulting your way or your Company's way; I'm adding my input to enhance the PCR writing skill you have. The 2 most important things the EMT does on a daily basis are not really covered in the EMT-B/I/P programs; PCR Writing and Ambulance Operations. All that are said is CYA; if you didn't write it, you didn't do it. Drive with due regard. There needs to be several sessions on documentation in the beginning and the end of the course: fundamentals and how would you document that. EVOC and Defensiving Driving Courses needs to be in the program. Is not done in NYS DOH EMS Programs; its not required. I'm just saying. All the best...

[JTpaintball70]

I basically use DCHARTE. HEre's a sample narrative.... lets say a 25 year old male found unresponsive by family in their bedroom.

Medic 2 dispatched code 3 to 124 Everyplace Lane for an unresponsive.

U/A pt is found to be a 25YOM who is unresponsive to outside stimuli.

PHX: As noted above, per family. (on my software that's a separate list, and lets say in this case it's IVDU, DM1, Asthma, and migraines)

HPI: U/A of EMS to scene, it appears that a mid-20s male is lying LLR on his bed. There appear to be no bottles of any medications or social substances around the patient. Patient appears atraumatic in presentation. Family asked for history on patient. Family states that the last time they saw the patient acting normally was approx 3 hours ago. Family prepared dinner and came to get the pt approx 20 minutes ago, and that's when it was discovered that he was unresponsive laying in bed. Family states he has been eating normally, and taking all prescribed medications on time and w/ the correct doses. Family denies that the patient has been ill recently, had any falls or injuries recently, and states his mentation has been normal. Family states nothing like this has happened to him in the past.

Mentation: GCS 7 (1-2-4), A&Ox0/4 (none due to unresponsive)

Skin: Cool, diaphoretic, normal coloration, good turgor.

HEENT: Pupils equal and reactive to light, 3mm. No fluid noted from ears or nose. No tenderness, crepitus, or deformity noted on palpation. Airway appears intact, with no snoring respirations.

Chest: Breath sounds clear and equal in all fields, normal depth and effort. No crepitus noted on palpation of ribs.

Abd: Soft, non-tender in all quadrants by palpation. No pulsatile masses noted on exam. No signs of trauma.

Extremities: Withdraws from painful stimuli, distal pulses present in all extremities, strong and regular. No gross trauma noted. No signs of recent injections.

Primary and seconday assessment performed. CBG reading obtained by EMT-I JT, reading of 'LOW' returned. Vital signs obtained by EMT-B Other Guy and as noted above. 18g IV established by EMT-I JT, R F/A using aseptic technique, 1 attempt, success. Running TKO NS on macrodrip set. No signs of infiltration noted around IV site, secured in place w/ Veiniguard and tape. 25g of D50 administered SIVP by EMT-I Zecco, attention paid to IV site watching for infiltration or any adverse affects, none noted. Upon successful medication administration, patient became to come around and became aware of surroundings. Patient was reassessed, and he stated that he gave himself his dose of insulin before eating, thinking the meal would be ready before it was. Patient states he is feeling much better now, EMS maintains their present location while patient eats dinner. Patient states he would rather not go to the hospital. IV is D/Cd, site covered w/ 2x2 and taped into place. Patient is told that EMS would prefer that he go to the hospital, and that there could be consequences of not being seen by an MD, up to and including death. Patient states he is aware of this, and signs refusal form. Pt is now A&O4/4, GCS 15. Pt is told if he starts to feel ill again, or if anything changes he is welcome to call EMS back. Patient states he will follow up with his PCP in the morning.

Medic 2 back in service from scene, en route back to quarters.

--------------------------------------------------

That's a sample of how I do reports... That call is completely made up and has no bearing on calls ran here in my AO

EDIT; Our E-PCR software has a list of 'events' which is where times for the procedures performed on scene are located. It means I only need to list what we did in the narrative, and not have to worry about putting times in it as well.

Edited February 5, 2011 by JTpaintball70

[fakingpatience]

My company E-PCR software for documentation. Generally for BLS calls, much of what you do is covered in the check boxes, but I still write long narratives- If I am going to need to back it up in court, I would rather defend my own words than a box I checked. The format I use for my narratives is SaCHART:

SA: scene assessment: what we were called for, how the scene looked, anyone else present, immediate impressions

C: Chief Complaint

H: History of presenting illness, any other pertinent history. This is the section where I tell the story of why we were called for the patient. I will also sometimes include in this section what we did on scene, depending on how it is flowing

A: Assessment. Here is what I include for the most part: AAOx4 (if not, elaborate), pink warm and dry. Denies LOC, dizziness, headache, light headedness, nausea, vomiting, diarrhea, recent trauma/ illness. No signs of trauma noted. HEENT: PERRL (anything abnormal noted), CHEST: Equal chest rise and fall, breath sounds clear and equal (if pertinent to pt, I will elaborate on no signs of SOB, no accessory muscle use...). ABD: Soft, non-tender. PELVIS: Stable, able to bare weight w/out pain. EXT: Movement of extremities x 4 w/out pain (I don't check CMS on every pt, especially if it is a medical issue, so I document it this way instead). BACK: (if trauma) Denies spine pain on palpation, no trauma noted.

Anything else pertinent from the exam. This is the section I will put a more detailed description of injury if trauma (since I can view an injury, making it more objective... I prefer to keep objective info in assessment vs. subjective info in history section)

Rx: any treatment we did for the patient

T: Transport. I usually write how pt got to the stretcher, transported non emergent w/out incident to XYZ ER. Pt left in care of ERRN, handoff and paperwork given to ERRN, no pt valuables handled.

There is a separate section in my PCR software for vitals, otherwise I would put them in my narrative

When I first started, I carried a cheat sheet w/ this info in my notebook, so when I was spacing on my PCRs, I could go back and see what I needed to put in. My PCRs generally end up being fairly long- my coworkers make fun of me for doing such long PCRs, but as I said above, I would rather defend my own words then a bunch of check marks. Also, I rarely remember the patient after that day, so should I need information about them later, I would need to get it from my PCR

[croaker260]

SO, My service (I hate the term "company", call me an idealist) transitioned about 5 years ago from strict SOAP narritive to a modified SOAP in an EPCR narritive to decrease redundancy. Some unfortunatley have digressed into lazy charting habits. I, as an FTO, find myself frequently correcting those habits. Here is a cut-n-past of several documents I use in my one on one training. The first part is a ddescripton of Proper SOAP charting writtten by one of the first EMTs I ever FTO'ed. She passed a number of years ago, but I kept the text to use.

SOAP Report Guidelines for EMS

By Karen Powers, EMT-AdvancedAdapted from Temple College's "Key Elements of SOAP Report Format."

When I was struggling with the chart-writing part of my training, one of my Field Training Officers suggested that I use the SOAP portion of the run report to "paint a picture." This helped me to focus on describing the call well enough that the reader could see what I saw and hear what I heard. However, make sure you don't include things that are irrelevant or judgmental. Thanks, Steve!

Subjective - What You Are Told

1. Describe the patient, specifically age and gender.

2. Chief complaint.

3. What the patient tells you, including history of the present event and answers to your OPQRST questions. Guess what ... if the patient has a potty mouth and this disposition is important to the situation, go ahead and include the quotes, but don't forget quotation marks!

4. What other people at the scene tell you: other responders, witnesses, police.

5. Previous medical history.

6. Current medications, physician(s).

7. Allergies.

Objective - What You See/Hear/Feel

1. Initial impression of the patient, including his or her location and position.

2. Vital signs, including breath sounds.

3. Physical exam findings and level of consciousness. It can be separated into primary (ABCDs) and secondary (body systems head to toe, so it's easy to remember).

4. General observations and other noteworthy information such as environmental conditions, patient behavior, etc.

5. Description of the scene, such as amount of damage to the vehicle's windshield, steering wheel and passenger compartment.

Assessment - Your Diagnosis

1. Diagnostic conclusion(s) based on the patient's chief complaint and your physical exam findings.

2. You may have more than one problem listed and can qualify each with "possible" or "rule out."

Plan - What You Did

1. This is the only portion of your patient care report that should be chronological.

2. Describe what was done for the patient and how he or she responded to treatment. This should include what was done prior to your arrival, how care was discontinued or transferred, and the condition of the patient upon departure.

You may want to include information about who had control of the patient's personal belongings upon your departure or where they were left. For example, if you left her purse in the tray underneath the hospital bed, make a note of it so you aren't to blame if the purse disappears.

Always keep in mind the importance of this document:

It is a medical record that must be treated confidentially, as defined by HIPAA regulations.

It is a legal document you may have to defend in court much later, after your memory has faded.

It is an historical record of the event from which a bill of service will be generated.

ALWAYS BE SURE YOUR RECORD DOES NOT CONTRADICT ITSELF

Other things to remember:

Often Legal action is taken because of Act of Omission, no Commission.

We are (most often) sued because of something that was not done.

We didnt treat a condition

We didnt provide transport

We didnt take time to…

Many times this results in a underlying perception that we didnt care enough to do our job.

It is important that our patient chart clearly shows that we were not just bystanders to the patients condition, but we took a pro-active part in being a pt advocate.

This changes the perception from us being a lazy medic who didnt take the time to transport (or treat) the patient to a caring individual who tried to take care of a patent but the patient (or situation) prevented it.

The second part of my document is a "Template" of a full SOAP format:

Medic XX dispatched to

S) Pt is a (age and sex) with a complaint of XX.

Pt denies

O) GENERAL- (Enter scene info, who attended the pt on your arrival, and interventions actively in place when you arrive)

VEHICLE- (Specific Vehicle damage info)

PRIMARY- LOC: (Mental assessment) A: (Airway, snoring, ect) B: (Labored, non labored) C: (Skin pallor, pulses, ect) D: Mini Neuro

SECONDARY-

HEENT: (Head-Ears-Eyes-nose-Throat)

NECK/BACK: (includes spine)

CHEST: (lung sounds, excursion, ect) ABD: (soft, tender, masses?)

PELVIS/EXT: Stability, distal motor function and sensation, etc.)

EKG: (Limb and 12 lead)

BG: mg/dl

SAO2:

A)

P) Pt contact, assessment.

This final part is the current "Modified SOAP" template;

SOAP Abbreviated for EPCR:Medic XX dispatched to

(S) Pt is a (age and sex) with a complaint of XX.

Pt denies

A review of her PMHx is remarkable for:

(O) On arrival we find a… who is in (enter distress level). (Then enter scene info, who attended the pt on your arrival, and interventions actively in place when you arrive)

VEHICLE- (Specific Vehicle damage info if it is an MVC)

While patients exam is noted elsewhere, it is remarkable for…

Then discuss LOC, Patients AFFECT, and IMPORTANT exam findings pertaining to her complaint.

Then briefly discuss vitals and/or hemodynamic status.

Then state: remainder of her exam is noted elsewhere in this chart

(P) Pt contact , report received from QRU, assessment and vitals obtained. Enter chronological discussion of call. Do not go into detail on every single event unless pertinent to the call and not dicussed elsewhere. It is OK to say Patient treated with nitrates, morphine and oxygen with a reduction in her chest pain to a 1/10 if the exact details of when and how you gave the interventions is discussed elsewhere. If it is not discussed elsewhere, and it is pertinent to the call, then feel free to document extensively.

And here is a HIPPA safe version of a modified SOAP:

Medic XX dispatched to a private residence for a fall patient.

(S)Patent is a XX y/o female with complaint of extreme pain to her left shoulder and upper arm. She states she tripped over her dog in the front yard. It is not believed she lost consciousness, and she fell to the grass covered earth. Complicating her presentation is the patients history of osteopenia, secondary to anti-rejection meds she is on for a heart transplant. Patent denies chest pain, back pain, neck pain, nausea, vomiting or SOB. She rates her pain as a 10/10, has evident tearfulness and guarding as well as anxiety associated with her injury, constituting a distracting injury.

(O)On arrival we find this female patient on the ground, attended by QRU in visible and verbal presentation of excruciating pain. The patient appears hemodynamically stable and in no life threatening distress. While her physical exam is noted elsewhere, it is remarkable for point tenderness to the proximal left humerus, increasing with any articulation at all. Patient is tearful , anxious in affect, and guards her extremity with any motion. It is noted to he extended in an awkward position , but no frank swelling nor false motion is noted. No sensation of crepitus noted. No deltoid flattening noted. She is neurologically intact, and palpation of her neck and back reveal no deformity nor tenderness. Remainder of her exam is as noted and unremarkable.

(O)On arrival, contact is made and assessment performed. IV access is obtained, and the patient is medicated with Fentanyl (analgesia) and Valium (for anxiety and muscle spasms). The left extremity is splinted with great care using the LSB, the scoop, a Large Vacuum splint, and copious amounts of padding and kerlex. Her pain is decreased and she is packaged to cot and then to MICU. Transport initiated to XYZ Hospital (patient choice based on previous admissions). She is immobilized as well. Over the course of transport, the patient is administered further doses of Valium and Fentanyl, with almost compete reduction of pain (1/10) . EMS arrives at XYZ Hospital . Full report to staff RN and Dr. FeelGood. Patients husband completes HIPAA. EMS clears.

SOAP Report Guidelines for EMS.doc Edited February 9, 2011 by croaker260