Report Writing

[Matt87]

Just a question....

I recently read an article online that was written by a Parameic. The article was about pre-hospital care reports and the format that this particular medic uses. They made the comment that on your report, you need to be as brief but accurate as possible. I find it very hard to be brief on my care reports, because when I write my reports, I try to be as detail oriented as possible. I think that paints more of a picture of what is really going on, versus just putting the information that I think is important at the time. If during my exam of a trauma patient I only find injury to the left arm, I will note that injury, but I will also note that all other extremities are without injury. This leaves no question as to whether or not a thorough assessment of the patient was performed. This is just an example, of course, but you get the picture. To be brief, in my opinion, leaves too much to be determined by the reader. Any opinions?

[nypamedic43]

Good report writing comes with practice. As for trauma injuries, this is how I write it ie: dcap-btls noted in left arm and left leg, no other dcap-btls noted.

I write very detailed reports and its gotten me into trouble. So over time, I have adjusted my report writing so that the chief complaint is there, how the patient presents,my assessment,how I get them to the stretcher, vital signs,interventions, how the patient responds to said intervention, what my findings are, radio report noted, med control orders, transfer of care to ED staff.

All the pertinent information is in my report, but I've pared it down to a paragraph or 2, depending on the call.

[JPINFV]

How could you get into trouble writing too detailed of a report?

[nypamedic43]

We have one person that does all of our QA/QI. I have always written detailed reports but he yelled at because they were so long. Told me that he had too many to do and mine take along time to read. I havent taken anything out, just condensed what I write.

[scubanurse]

I've known a few QA/QI folks like this... I ignore them and tell them that it's their job just like it's my job to write the reports....

[tcripp]

In a nut shell, you need to write just enough to help you remember the call in court 5-10 years from now and not too much to make it unreadable. And, to top it off, it you don't write it...it didn't happen. UGH! Now where do you draw the line.

If your PCR has fill in the blank or drop down boxes in an ePCR, use that for as much of your information as possible. Then, add in the little bit of extra without being redundant in your narrative. Many ePCRs are getting to the point to where you don't even have a narrative feature any longer, just an extra comment box.

I agree with you on how you note your trauma. If I only note the one injury without stating, no other dcapbtls noted...how do they know I ever looked at the rest of the body? My opinion, I think you are on the right track and, with practice, will get a better feel for what needs to be included vs not.

Toni

[Kiwiology]

Don't write a novel, write something that is concise and clinically relevant yet of appropriate length

It takes practice, I used to be absolute bloody rubbish at writing PRFs

[tcripp]

It takes practice, I used to be absolute bloody rubbish at writing PRFs

PCR = patient care report

ePCR = electronic patient care report

PRF?