Please help me improve my narratives

[CPhT]

The topic came up between my partner and I today that our narratives are vastly different, and she seems to think that I'm including a lot of extra words and info, when it isn't needed. I have only been doing this for 4 months now, but I've been doing process documentation for the better part of 2 decades, so I thought I had a decent grasp on what was needed. So... for your entertainment and critique, here is a sample of a completely fictional narrative. I'm a Basic EMT, but I'll be starting medic classes in August, so I'm sure my narrative will be evolving even further after that. Feel free to pick it apart as needed.

Typical transport:

B582 dispatched non-emergent to (hospital) for pre-scheduled transport of pt to (other hospital) for rehabilitation services not available at (hospital). PT was admitted to (hospital) for rt knee replacement surgery, treated, and cleared for transport to (other hospital). PT requires ambulance transport due to unsteady gait, and pt is at risk for falling off stretcher. ATF 70 yo female pt laying semi-fowlers in hospital bed. Pt assessed, found to be AOX3. Pt denies cp, denies sob/dib. Pt states she currently has pain in her rt knee at the incision, which she rates 7/10. Nursing staff administered pain control medications approximately one hour ago. Pt denies any other pain at this time. Pt vitals checked (tech initials): BP120/70, P70, RR16, SPO2 99%RA. Pt is unable to stand due to surgery, pt moved from hospital bed to ambulance cot via draw sheet, secured to cot railsx2, strapsx5. Pt moved to ambulance, loaded, secured to floor rail. Pt transported to (other hospital) non-emergent, monitored for safety en route and vitals rechecked prn. Upon arrival at (other hospital), pt unloaded from ambulance, taken inside to rehab wing, and taken to her room. Pt moved from ambulance cot to hospital bed via draw sheet, positioned for comfort, and rails raised. Report and paperwork given to nursing staff. Care transferred to receiving facility. B582 cleared without incident. (tech signature)

Typical Emergency:

B582 dispatched priority one to (city) residence for chief complaint of altered mental status, possible diabetic emergency. B582 responded emergent to scene without incident. ATF 30 yo male pt seated on city easement with (city) PD on-scene and at the pt side. Pt appears AOx1, conscious and alert, but disoriented. Pt responds to his name, but answers questions incoherently. (tech initials) retrieved glucometer, checked level, BGL 20mg/dl. Pt given one tube of insta-glucose orally, pt condition immediately improved. Pt LOC increased to AOx3. Pt denies pain, denies sob/dib. Pt denies alcohol or drug usage. Pt states he is a diabetic and took his insulin without eating lunch. Pt agrees to examination by EMTs. Assisted pt in standing and walking to ambulance, helped into pt compartment, and seated on squad bench. Pt vitals checked (tech initials): BP100/50, P100, RR20. Pt agrees to go to (hospital). Pt moved to stretcher, positioned for comfort and secured railsx2, strapsx5. Pt transported priority 2 to (hospital). (Hospital) contacted via HEMS radio patch. Upon arrival, pt unloaded and taken to ER Pod C. Report given to nursing staff. Care transferred to receiving facility. B582 cleared without incident. (tech signature)

[Just Plain Ruff]

Ok, first off you have abbreviations and if you are using abbreviations does your service have an approved abbreviations list? That's important.

I also do not see a head to toe assesment listed.

My report format always will have a head to toe assessment.

I will PM you my report format.

My report format may work for you but may not work for others. I've used it for over 19 years with only a single trip to court.

[Eydawn]

Looks OK to me. No inferences, no assumptions...

I might leave out stuff like "transport to X facility d/t resources not available at facility of origin"- if it's an interfacility, you can just state transfer of pt from X facility to Y facility for continuation of care...

I might include MORE of why the patient is at risk; for example: "Pt transported via ambulance d/t risk of falling from stretcher as evidenced by (AEB) unsteady gait and reported incidence of near falls at originating facility" (since I'm guessing you're justifying why they were tx'd via ambulance instead of POV).

I err on the side of overcharting vs undercharting, TBH. I'd rather spell it out. After all, if I'm going to be in court with it someday, I want to be able to say "I have nothing further to add, my documentation is complete as recorded at time of charting. Please refer to charting for specific questions."

I think your charting style is JUST FINE. Be consistent in what abbreviations you use to mean what, and you'll be golden... I actually shy away from most abbreviations except for AEB (as evidenced by), c/o (complains of), d/t (due to) and r/t (related to). Occasionally you'll find me using SOB for shortness of breath.

Wendy

CO EMT-B

[CPhT]

Ok, first off you have abbreviations and if you are using abbreviations does your service have an approved abbreviations list? That's important.

I also do not see a head to toe assesment listed.

My report format always will have a head to toe assessment.

I will PM you my report format.

My report format may work for you but may not work for others. I've used it for over 19 years with only a single trip to court.

Oh yeah, I should have mentioned that. All of the abbreviations I used are approved by our med control authority, and we have about 5-6 pages of TLAs (three-letter-acronyms) we can pick from.

That's pretty much what I'm looking for, is a bullet-proof narrative that I'm not afraid to take to the Quality Control group, or to a courtroom. Thanks!

Looks OK to me. No inferences, no assumptions...

I might leave out stuff like "transport to X facility d/t resources not available at facility of origin"- if it's an interfacility, you can just state transfer of pt from X facility to Y facility for continuation of care...

I might include MORE of why the patient is at risk; for example: "Pt transported via ambulance d/t risk of falling from stretcher as evidenced by (AEB) unsteady gait and reported incidence of near falls at originating facility" (since I'm guessing you're justifying why they were tx'd via ambulance instead of POV).

I err on the side of overcharting vs undercharting, TBH. I'd rather spell it out. After all, if I'm going to be in court with it someday, I want to be able to say "I have nothing further to add, my documentation is complete as recorded at time of charting. Please refer to charting for specific questions."

I think your charting style is JUST FINE. Be consistent in what abbreviations you use to mean what, and you'll be golden... I actually shy away from most abbreviations except for AEB (as evidenced by), c/o (complains of), d/t (due to) and r/t (related to). Occasionally you'll find me using SOB for shortness of breath.

Wendy

CO EMT-B

Thank you for the insight. It definitely took me a while to get used to using SOB for shortness of breath, as opposed to... well, you know. We basically have 2 things that my service requires in our IFT narratives:

1. Why they require ambulance transport (rather than non-emergency van "wheelchair van", or even POV)

2. What services are available at hospital X that aren't available at hospital Y

To my understanding, it has something to do with insurance coverage, and getting medicare to pay for the ride. Thankfully, if it's an emergency, all bets are off and we don't have to spell those things out.

I agree with overcharting vs undercharting too, I'd rather have too much info than not enough, in the event that my quality of care ever comes into question.

[Just Plain Ruff]

One thing you should never ever do is lie on your reports and many IFT services sometimes require you to do that. They make you put something like "Granny requires ambulance transport because she cannot ambulate to cot" or "Granny required assistance from bed to cot" when in reality she moved herself to the cot. Medicare audits charts and when they see discrepancies in charts from one service saying that they had to assist granny to the cot while all the other services have her not being assisted then they will do a deeper audit and they may nail your service for medicare fraud.

So be careful when your service starts to require you to vomit out the narratives that they are having you write out in your numbered items in your last post. That's a red flag that to me that they are trying to get their techs to possibly commit some type of fraud.

I've been in those shoes before and it was not pretty.

[FireEMT2009]

The topic came up between my partner and I today that our narratives are vastly different, and she seems to think that I'm including a lot of extra words and info, when it isn't needed. I have only been doing this for 4 months now, but I've been doing process documentation for the better part of 2 decades, so I thought I had a decent grasp on what was needed. So... for your entertainment and critique, here is a sample of a completely fictional narrative. I'm a Basic EMT, but I'll be starting medic classes in August, so I'm sure my narrative will be evolving even further after that. Feel free to pick it apart as needed.

Typical transport:

B582 dispatched non-emergent to (hospital) for pre-scheduled transport of pt to (other hospital) for rehabilitation services not available at (hospital). PT was admitted to (hospital) for rt knee replacement surgery, treated, and cleared for transport to (other hospital). PT requires ambulance transport due to unsteady gait, and pt is at risk for falling off stretcher. ATF 70 yo female pt laying semi-fowlers in hospital bed. Pt assessed, found to be AOX3. Pt denies cp, denies sob/dib. Pt states she currently has pain in her rt knee at the incision, which she rates 7/10. Nursing staff administered pain control medications approximately one hour ago. Pt denies any other pain at this time. Pt vitals checked (tech initials): BP120/70, P70, RR16, SPO2 99%RA. Pt is unable to stand due to surgery, pt moved from hospital bed to ambulance cot via draw sheet, secured to cot railsx2, strapsx5. Pt moved to ambulance, loaded, secured to floor rail. Pt transported to (other hospital) non-emergent, monitored for safety en route and vitals rechecked prn. Upon arrival at (other hospital), pt unloaded from ambulance, taken inside to rehab wing, and taken to her room. Pt moved from ambulance cot to hospital bed via draw sheet, positioned for comfort, and rails raised. Report and paperwork given to nursing staff. Care transferred to receiving facility. B582 cleared without incident. (tech signature)

Typical Emergency:

B582 dispatched priority one to (city) residence for chief complaint of altered mental status, possible diabetic emergency. B582 responded emergent to scene without incident. ATF 30 yo male pt seated on city easement with (city) PD on-scene and at the pt side. Pt appears AOx1, conscious and alert, but disoriented. Pt responds to his name, but answers questions incoherently. (tech initials) retrieved glucometer, checked level, BGL 20mg/dl. Pt given one tube of insta-glucose orally, pt condition immediately improved. Pt LOC increased to AOx3. Pt denies pain, denies sob/dib. Pt denies alcohol or drug usage. Pt states he is a diabetic and took his insulin without eating lunch. Pt agrees to examination by EMTs. Assisted pt in standing and walking to ambulance, helped into pt compartment, and seated on squad bench. Pt vitals checked (tech initials): BP100/50, P100, RR20. Pt agrees to go to (hospital). Pt moved to stretcher, positioned for comfort and secured railsx2, strapsx5. Pt transported priority 2 to (hospital). (Hospital) contacted via HEMS radio patch. Upon arrival, pt unloaded and taken to ER Pod C. Report given to nursing staff. Care transferred to receiving facility. B582 cleared without incident. (tech signature)

In my limited spectrum of knowledge here I only have a few things that I do in my narrative that made it through my paramedic program and was never asked for clarification. You have a great meat and potatoes now just add some gravy and sides and you will be good to go. The rules I follow are:

I never use abbreviations, every career has different terms for different abbreviations, so I follow the cop rule, abbreviate nothing.

When I say my patient is alert and oriented times 3, I always put to what they were oriented to such as: Patient is alert and oriented to person, place, and time, but could not identify what event had taken place. That way its there in case it ever gets called to court.

I always try to include my SAMPLE, OPQRST at the bottom of my narrative for emergent and non-emergent if possible. So it looks like this:

Narrative

S

A

M

P

L

E

O

P

Q

R

S

T

Name, EMT-B/I/P

That way if it ever shows up in court, you have your Objective and Subjective assessment in there.

I always make sure that whoever I recieve or give report from, I always include where I left the patient, who was in the room and what relation/ level of care provider they are, RN, MD, DO, wife, mother, husband, etc. I document all names whether it seems insignificant or not it might be useful later. I also will note whoever gives medication, the amount (1 half tube of oral glucose, 1 tube of oral glucose, etc. that way there is no confusion later.

Also, especially while precepting for your medic ask to see your preceptors way of narratives and pick up good points and learn to mix them into yours.

On every patient I will always give my ABCs such as:

Patient was found sitting in the chair, Patient is alert and oriented to person, place, time, and event. Patient's airway is open and patent without intervention. Patient's breathing and circulation are life sustaining without intervention. Patient is breathing 16 times per minute, equal and bilateral chest movement noted, lung sounds clear. Patient is not experiencing any labored or difficulty breathing or showing any signs of respiratory distress or failure. Patient's pulse is 76 strong, regular, radially. Patient's skin is warm and pink with nothing remarkable. etc.

Just my two cents.

[Kiwiology]

I have made an observation that Americans always put in too much crap, keep it simple

Typical transport:

B582 dispatched non-emergent to (hospital) for pre-scheduled transport of pt to (other hospital) for rehabilitation services not available at (hospital). PT was admitted to (hospital) for rt knee replacement surgery, treated, and cleared for transport to (other hospital). PT requires ambulance transport due to unsteady gait, and pt is at risk for falling off stretcher. ATF 70 yo female pt laying semi-fowlers in hospital bed. Pt assessed, found to be AOX3. Pt denies cp, denies sob/dib. Pt states she currently has pain in her rt knee at the incision, which she rates 7/10. Nursing staff administered pain control medications approximately one hour ago. Pt denies any other pain at this time. Pt vitals checked (tech initials): BP120/70, P70, RR16, SPO2 99%RA. Pt is unable to stand due to surgery, pt moved from hospital bed to ambulance cot via draw sheet, secured to cot railsx2, strapsx5. Pt moved to ambulance, loaded, secured to floor rail. Pt transported to (other hospital) non-emergent, monitored for safety en route and vitals rechecked prn. Upon arrival at (other hospital), pt unloaded from ambulance, taken inside to rehab wing, and taken to her room. Pt moved from ambulance cot to hospital bed via draw sheet, positioned for comfort, and rails raised. Report and paperwork given to nursing staff. Care transferred to receiving facility. B582 cleared without incident. (tech signature)

History of right knee surgery - transfer to XX hospital for rehab

O/A 70 yo female pt in hospital bed, unable to stand

O/E AOX3. no chest pain or SOB obs BP120/70, P70, RR16, SPO2 99%RA

C/O Pain right knee at surgical incision 7/10 - xx mg yy analgesic given by RN 1/24 ago

Transported to other hospital - no change during transport

B582 dispatched priority one to (city) residence for chief complaint of altered mental status, possible diabetic emergency. B582 responded emergent to scene without incident. ATF 30 yo male pt seated on city easement with (city) PD on-scene and at the pt side. Pt appears AOx1, conscious and alert, but disoriented. Pt responds to his name, but answers questions incoherently. (tech initials) retrieved glucometer, checked level, BGL 20mg/dl. Pt given one tube of insta-glucose orally, pt condition immediately improved. Pt LOC increased to AOx3. Pt denies pain, denies sob/dib. Pt denies alcohol or drug usage. Pt states he is a diabetic and took his insulin without eating lunch. Pt agrees to examination by EMTs. Assisted pt in standing and walking to ambulance, helped into pt compartment, and seated on squad bench. Pt vitals checked (tech initials): BP100/50, P100, RR20. Pt agrees to go to (hospital). Pt moved to stretcher, positioned for comfort and secured railsx2, strapsx5. Pt transported priority 2 to (hospital). (Hospital) contacted via HEMS radio patch. Upon arrival, pt unloaded and taken to ER Pod C. Report given to nursing staff. Care transferred to receiving facility. B582 cleared without incident. (tech signature)

History of diabetes, today took insulin without eating lunch

O/A pt seated on city easement with police; conscious and alert but disoriented

O/E secondary survey normal, BP100/50, P100, RR20 BGL 20mg/dl

One tube of insta-glucose po - LOC increased to AOx3

No chest pain, SOB, alcohol/drugs

No change during transport

Use the nine point plan

PMHx

Meds

FMHx

SHx

Complaint

O/A (upon arrival)

O/E (upon examination)

Treatment

Disposition

Edited May 31, 2012 by Kiwiology

[Aprz]

I think it's all right. I know you gave an example so I am not sure if it was purposely left out, but I'd write the last name and level of training from people who you received and a report from and who you gave a report to.

"Received a report and paperwork from Smith, RN."

It's really not that hard to ask them for their last name or look at their name tag, and be honest "Can I have your last name so I can write down who I gave a report to?"

Like names, I think it's nice to include the department and room number (e.g. ER room 12) of the hospital too.

I used to write non emergent too, but the company I currently work for recommended that I did not write that. They prefer that I write "without red lights and sirens" or "without warning devices" or priority/CODE it is. Something about even if it's without red lights and sirens, it could still be considered an emergency, but one that doesn't require red lights and sirens. Since you are mentioning that you transported without red lights and sirens, you minus well mention how you responded too (even though to us, it's a given that you didn't respond with 'em).

In your first example, you forgot to mention the patient's position on the gurney.

I think it's standard to say the medication name, dose, route, who it was administered by, when, and how the patent tolerated it. I think it would be easier to give an actual time rather than saying one hour ago "1 mg Dilaudid by Smith, RN at 1400. The patient said it reduced her pain from a 10/10 to a 7/10". At least a name, dose, and time in case your patient begins to crash during transport and you have to transfer your patient to ALS or give a report in the ED. It's no fun saying "I don't know" or "It's in the paperwork" when you are giving a report in the ED or to ALS.

Do you have a section to write down your vital signs? Reading the PCR, it sounded like you only had one set of vital signs. It's nice to get the last one from the hospital (write a note like "VS prior to transport at sending facility by Smith, RN done at 1400 HR 72, BP 120/80, RR 16, Temperature 98.6F orally, SpO2 100% on Room Air", even vital signs you won't record that you can at least relay to the receiving facility (in my area, we don't regularly check temperature and EMT's are not allowed to do pulse oximetry so we don't have a section for it on our PCRs), a baseline set of your own on your own equipment, and at least one more to watch for trending. I believe medicare requires at least 2 sets of vital signs.

In my area, AOx3 would be considered confused. Anyhow, you could be specific to what they were alert and oriented to "alert and oriented to person, place, time, and event". Ah, I actually see you did it in the second narrative. Yeh, just like that... I liked how you mentioned incoherently. You could also mention if they talked fast/slow, soft/loud, and if they were clear/distinct. "Speech is slow and words are mumbled."

You said that the patient had an unsteady gait, but later on you said she can't stand. See a problem? If the patient can't stand, the patient can't gait . Is the patient unable to stand physically, is standing not recommended by the patient's doctor, does pain increase when the patient stands, did the patient refuse to stand?

Mention if there were any changes during transport.

Captain ToHellWithItAll is right, I don't see a physical exam in there. I don't see any physical assessment on the right leg at: Can the patient move it? Is there a scar from the incision? Does it hurt when the patient moves or stands on it? Is circulation, motor, and sensory intact? What is it like compared to the other leg? Any edema? Warm to touch?

I think we act like witnesses and should support/verify other documentation on the patient. In other disciplines of the medical field, your documentation represents how good of a provider you are. I think that some information is considered worthless if it's partial e.g. saying "RN" instead of "Smith, RN". I'm not suggesting you would go to court over a transport like that, but if you did, I am pretty sure the court would be interested in names rather than just level of training. It's difficult for me to explain what I think would be excessive for a PCR. Like I think if the patient told me about their 4 grandchildren during transport and how one of them is really good at dodgeball, I think that is worthless information to include on a PCR, although writing about the patient being able to talk clearly and coherently, how loud or soft they spoke, how fast or slow they spoke, etc is important (especially when transporting a patient with dementia). See what I mean? I think you are on the right track with your narratives.

Edited May 31, 2012 by Aprz

[DwayneEMTP]

Man, great advice from all...

I would add only this, as I think that technique is often focused on and it's missed...

Try and create a useful document. This is a record of a person's life, and sometimes death.

There is nothing wrong with Kiwi's version of a PCR that I can see. In fact my car mechanic uses nearly the exact same format. But we're not working on cars, and the physical/physiological absolutes are rarely going to be the only things that I want future care to understand about what I found, what I did, and why.

It seems obvious, right? I don't think it is. Some create to cover their asses, others to brag about their clever brevity, some so that no one can get anything useful out of it to take to court. Some are great at abbreviations and 300 character PCRs, but I'm not convinced that those always tell the whole story.

We're patient advocates first, rockstar medics that can create technically correct, brief, bragable PCRs second. Your notes are moments in a person's life that will be the only window for other medical professionals to see through into those moments. Make sure that you don't fog that window by trying to be clever instead of thorough.

I once heard a medic brag that because she's been chastised for using too many abbreviations that she wrote several PCRs without ever creating a whole word if she could figure out a way to avoid it. She was a bitch, and a shit medic, and the only type of person that I can think of that would be proud of polluting a patient's records with such nonsense to make a point.

Abbreviate often if you like, or, like me, almost never, but never forget that you're telling the story of your time with an honest to God human being that not only trusted you to care for them, but trusted you as their liaison to further medical care as well. Your PCR should clearly show that you are deserving of that trust.

[ERDoc]

A lot of the way you document will be based on what your paper/computer setup looks like. I'd say there is a lot of information in there that doesn't need to be. Do you really need to state that you locked the strecher into the floor mount? I also see a lot of people stating that they document what room the got the pt from and dropped them off. What is the relevance?