Please help me improve my narratives

[nypamedic43]

NYS Medicare only requires 1 set of vital signs. They require the following: HOW the patient was moved ie: walked to stretcher or if you state the patient is unable to ambulate, they were moved to the stretcher using bed linen, then at the receiving facility..they were moved from the stretcher using same linen or stretcher linen. They also want to WHY the patient is requiring an ambulance, ie: patient requires ambulance transport because of hx of right hip fracture and needs stretcher for positioning for pain, or patient has a hx of dementia and requires supervision during transport.

We use the Zoll EPCR program. It's customizable to your services needs and helps shorten your narratives so you dont need to repeat v/s, medical history etc into your narrative. All our signatures are in the database so we don't need to sign them.

[Iowa Medic]

I'm a bit lost as to why anyone would suggest a medical run report would be to "wordy" unless said words were useless and not deliberately going towards thoroughly explaining patient condition, care or transport.

My narratives are often looked upon as long winded with "useless pertinent negatives" but I find it odd that one would call them pertinent negatives if they weren't pertinent.

All I can say is that I've never had an officer in the department suggest I make my reports shorter for the sake of allowing more time for breaks etc.

Ambulance 4 and Company 1 dispatched to 12345 generic street america for a report of a 236 year old complaining of chest pain.

Company 1 arrived on scene establishing 12345 generic street america command.

Ambulance 1 arrived on scene to find 236 year old male patient found sitting upright in bed with feet placed on the floor approximately shoulder width apart. Residence appears to be well kept, free of debris and obstruction. Patient is awake, alert and oriented in no apparent distress at this time. Patient either is or is not using accessory muscles to breathe/tripod positions etc. Patient currently denies shortness of breath, difficulty breathing or other medical complaint at this time other than chest pain which he describes as "sharp, stabbing pain" which is non radiating, rates as a 7/10 and is increased upon palpation and inspiration. Patient has no known drug allergies, has a history of type 2 diabetes, COPD, blah blah blah.

Patient transferred from sitting position to ambulance cot via (assistance, sheet lift, extremity carry etc due to syncopal episode, non ambulatory, pain upon movement, orthostatic hypertension, patient safety etc) and transported to ambulance secured to cot without incident.

Ambulance 4, Company 1 clear of 1234 generic street america en-route to Holy Crap Hospital, there by discontinuing 1234 generic street america command.

Initial assessment reveals:

Airway - patent

Breathing - (describe)

Circulation - no visible bleeding

BP

Pulse

Respirations

Lung Sounds

Skin

Pupils

Neuro's

SAo2

End tidal CO2

Cap refill

Rapid head to toe assessment (DCAP-BTLS etc)

H

E

E

N

T

Chest - Paradoxical movement, crepitus, lung sounds

Upper extremities - grip strength, pulses

Abdomen - bowel sounds, soft, non tender, rigid, pain upon palpations

Pelvis - stable, denies pain etc

Lower extremities - equal pedal pulses, dorsi flexion/extension

Signs

Symptoms

Allergies

Medications

Past pertinent medical history

Last oral intake

Events leading up to chief complaint

Interventions:

Cardiac monitor - NSR or changes that may suggest 12 lead

12 lead -

IV - reason for IV, Size Fluid etc

O2 administration - reason for 02

Cpap - due to inability to increase 02 levels with nasal or nrb if indicated

Board/block collar - if indicated

Drugs - indication for drugs along with expiration date, allergies, contra indications, relative contraindications

Vitals/pain assessment post interventions

Pulses etc post interventions

Ongoing assessment

BP

Pulse

Respirations

Skin

Lung sounds

Pupils

Neuros

SAo2

Patient continues to deny shortness of breath, difficulty breathing or other medical complaint other than chest pain which is rated as a 4/10, described as crushing, pain increased upon palpation and inspiration etc

Further Head to toe if warranted or if not warranted if time allows

Patient continually monitored throughout transport with (insert changes or lack of changes to condition). Patient continues to deny blah blah blah but still expresses (insert chief complaint)

Insert monitoring of interventions (IV, Drugs, post vitals for said drugs, how they tolerate splinting, pulses/movement post splinting)

Patient transported into blank ER via cot, connected to (02, monitor, pulse ox, IV etc and results of said devices) patient transferred to hospital bed #3 via sheet lift without incident and care transferred to Nurse Babcock RN at Holy Crap Hospital ER.

EDIT: I also list all vital signs in my narrative which I know is redundant given the nature of Firehouse. I also list any and all exams, questions, comments etc in their correct chronological order in the flow of the narrative.

I am not saying this is verbatim my narrative given I'm on little to no sleep but this is a general idea with the focus on telling a factual story in chronological order of how the entire run from dispatch to transfer of care happened.

When (not if) you are in court an exact run down of the call will be invaluable when you are attempting to testify 2 years post incident. Also I think these types of run reports make you a better practitioner, especially if you like me are a new medic.

EDIT: Last thing,,, Trick is to save a great run report to a word document with no times, addresses, patient info etc and label it as "Chest pain, Abdominal pain, Car crash, Motorcycle crash, Shooting, Stabbing etc" so in future calls which are similar in nature you can recall your report. I'm not suggesting using a template but at 4 in the morning it's great motivation and a helpful guide to write a great report on little to no sleep.

Edited May 31, 2012 by Iowa Medic

[Iowa Medic]

I would love to add a personal spin on this post given the subject matter and unwillingness to clutter up the board with my own topic...

How do those who have been at this for years feel about my above narrative? Is it on point? Would you add anything to said narrative? Would you phrase or list anything in a different manner? Did I add anything unnecessarily that adds little to patient care and increase my susceptibility in court?

[Just Plain Ruff]

Iowa, where are you saving your reports to in order to recall them? If you are saving them anywhere other than the company computer and it's accesible to anyone then you run the risk of patient confidentiality problems. Be careful is all I will say.

Here is my format.

Call type Chest pain call

Called emergency to the scene of a man complaining of chest pain. On arrival found a 47 year old male patient sitting in the kitchen complaining of severe chest pain which started 20 minutes prior to EMS being called. Family states that patient has a history of heart disease and high cholesterol. Patient relates that his chest pain is substernal in nature and radiates to his left arm and into his jaw. Patient also relates that he has been under some pretty significant stress over the past week or so.

Exam:

Heent: head, ears, eyes, nose, throat

Neck: any jvd, trachea ok?, exam of neck

Chest: what is the chest exam like?

EKG: whats the EKG look like (12 lead and 3 lead)

Lungs: lung sounds

Back: Back exam

Abdomen: bowel sounds, abdomen exam

Pelvis: pelvic rock, any trauma

GI/GU: what’s the urine look like, any diarrhea? Does the patient have a foley? Vaginal bleeding? BABY?

Extrem: fractures? Lacs? Etc,

Skin: skin turgor, skin color, skin temp

Neuro: What’s their neuro status? You can put pupil response here or put it up in the HEENT section

I/I: Impression and Impact this is what you think is going on - This is not a diagnosis area. You can put something like “Suspect Fractured femur” or Suspect GI Bleed” or “Suspect CVA” NEVER NEVER put a diagnosis always preface with Suspect or Rule/Out

Treatment: Number your treatments for example 1:Exam 2: Vitals 3: Monitor 4: 12 lead EKG 5: Oxygen 12 liters Non rebreather mask 6: IV NS 18 ga left AC 125ml per hour and so on and so on etc etc 34: transport emergency to Hospital Alpha 35: Radio report to Dr. Jones with no order requested or received 36: arrived at Hospital Alpha with no change in patient condition 37: care turned over to Nurse Ratchet 38: Report signed by Nurse Ratchet

You can modify this report format as you wish or not use it. It’s up to you. This is my report format that was taught to me by a very good friend who is a paramedic and an attorney and I have only been to court one time in my career and it was not based on my documentation. There was a question based on the documentation but it was the circle the boxes of the state form and not the narrative section.

Good luck with whatever format you choose.

I would strongly urge you to find if you can, it will be difficult to do but if you can find it I urge you to buy it, the book called “The fourth protocol” by Kate Doernocour (spelling might be wrong) It’s based on documentation and how to write a legally defensible report. One of the best books on writing a report. IT doesn’t teach you how to write a report but what to put in your report to make it be nearly lawyer proof.

Michael

[Bieber]

I tend to agree with Kiwi on the benefits of simple, concise PCR's. At my service, our ePCR's generate a narrative format that imports information inputted above (vitals, treatments, etc) and we type in an HPI, review of systems, and outcome. I'm not near as concise as Kiwi is, but I'll give an example based on the scenarios above.

Scenario 1

Intro: On (date), unit (#) responded to (hospital A address) on a reported (dispatch code for non-emergency transport)

C/C: Patient is a 70 years old female, c/o unknown medical

HPI: Patient is being transported today from (hospital A) to (hospital for continued care following a right knee replacement surgery. At time of patient contact, patient presents alert and oriented x3 in no acute distress. RN staff state that they administered pain medication approximately one hour ago. Patient is pain free at this time.

PMH: right knee replacement

Allergies: NKDA

Medications: None

Assessment:

HEENT: pupils left (reacts) right (reacts). Normal on inspection.

Neck: Normal on inspection.

Chest: Equal chest rise, adequate depth of respiration.

Lungs: right (clear), left (clear)

Abdomen: No complaints.

Pelvis: Not assessed.

Posterior: Not assessed.

Extremities: Neurovascular function intact x4, bandage to right knee (presumably).

Injury: None.

Systems:

CV: Radial pulse strong and regular.

Resp: rate (normal), (unlabored)

Neuro: AVPU (alert), initial GCS (15)

GI/GU: No nausea/vomiting.

Integ: skin color (normal), temp (normal), condition (normal), less than cap refill (2sec), edema (none).

Vitals:

(time) BP:120/70 HR:70 R:16 Sats: 99%

Provider Impression: right knee replacement, non-ambulatory

Treatment: Assessment and transport.

Outcome: Patient was moved from scene to the ambulance via stretcher. Patient was reassessed en route with no additional complaints or acute changes noted en route. Patient care was transferred to RN staff at hospital B.

On to scenario numero dos....

Intro: On (date), unit (#) responded to (incident location) on a reported (dispatch code for diabetic emergency)

C/C: Patient is a 30 years old male, c/o diabetic emergency

HPI: EMS dispatched by PD for a patient complaining of a possible diabetic emergency. PD states that the patient was found in his current state. Patient has a history of diabetes and reports having taken his insulin today without eating afterwards. Patient presents verbal confused with no injuries or other complaints at this time and states that he took his insulin earlier today and has not eaten anything since then.

PMH: diabetes

Allergies: NKDA

Medications: insulin

Assessment:

HEENT: pupils left (reacts) right (reacts). Mucous membranes moist, no abnormal nose/ear discharge.

Neck: Normal on inspection.

Chest: Equal chest rise, adequate depth of respiration.

Lungs: right (clear), left (clear)

Abdomen: No complaints.

Pelvis: Not assessed.

Posterior: Not assessed.

Extremities: Neurovascular function intact x4.

Injury: None.

Systems:

CV: Radial pulse strong and regular.

Resp: rate (normal), (unlabored)

Neuro: AVPU (verbal), initial GCS (14)

GI/GU: No nausea/vomiting, incontinence.

Integ: skin color (pale), temp (cool), condition (moist), less than cap refill (2sec), edema (none).

Vitals:

(time) BP:100/50 HR:100 RR:20 Sats: 99% BGL: 20

(time) BP: 100/50 HR: 90 RR: 16 Sats: 99% BGL: 200

Provider Impression: diabetic emergency

Treatment:

(time) IV access; 20 ga; L AC

(time) NS 1000; rate: TKO; dose: 40 mL

(time) Dextrose; dose: 25 gm; route: intravenous

Outcome: IV access was obtained and patient was administered dextrose following which he had an immediate increase in his level of consciousness and a complete resolution of all symptoms. Patient was reassessed and was made to eat a protein-rich meal in our presence and was advised to recheck his blood sugar in 2 hours. Patient was also advised to follow up with his regular physician. Patient refused transport via EMS and signed the refusal form. Patient left on scene with PD.

(I added my own little spin to this... enjoy! Also, Dwayne, please see this and rage at the refusal!)

[cscboulder11]

I would love to add a personal spin on this post given the subject matter and unwillingness to clutter up the board with my own topic...

How do those who have been at this for years feel about my above narrative? Is it on point? Would you add anything to said narrative? Would you phrase or list anything in a different manner? Did I add anything unnecessarily that adds little to patient care and increase my susceptibility in court?

I'm curious as to why you included what the pt's home looks like unless it was cluttered enough (think hoarder) to interfere with any treatments or posed a risk to either you or the pt, or you noticed any drug paraphernalia.

[paramedicmike]

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?

That may be an orginazational requirement.

Several organizations with which I'm familiar have had similar documentation requirements simply from a legal protection standpoint. Their argument was that if, for example, it is documented that the stretcher was loaded and locked into place a lawyer couldn't come back later and argue that the stretcher wasn't properly loaded or secured when the 18 wheeler t-boned the ambulance causing the stretcher to fly out the gaping hole torn into the box.

There are a lot of people out there terrified of both lawyers and lawsuits. Some of the hypothetical situations they'll come up with to justify their requirements can be interestingly entertaining.

[Just Plain Ruff]

Yeah, I had a service telling me that I had to say in my narrative "secured with 3 straps and cot secured to ambulance. Total mileage 33.34 miles"

[CPhT]

Wow, you guys and gals are amazing with your recommendations. I'm on the road right now riding shotgun for the return trip of a long distance transport, so I have to keep it short. Fat fingers, lots of caffeine, and a tiny keyboard...

In any case, I'm going to play around with some ideas when I get back to the station and maybe post an updated report.

Most of the stuff I include in the narrative is more for the legal/ cover-your-ass aspect. Things like pt secured, stretcher secures, etc. The ePCR software (Zoll RescueNet) we use has sections for subjective and objective assessment, vitals, PMH, meds, allergies, and interventions. All the goodies. I like the software. I kinda want to print a fake paper report just to see what all comes out.

In any case, I'll check back when I get home or to station. Thanks again!

EVO using Tapatalk 2 - "I should be working"

[Iowa Medic]

Iowa, where are you saving your reports to in order to recall them? If you are saving them anywhere other than the company computer and it's accesible to anyone then you run the risk of patient confidentiality problems. Be careful is all I will say.

Michael

I save it to the fire departments secure drive that has an individual file for each department member. There is no patient confidentiality issues as there is no patient information in said report. Address, names, companies responding, vitals etc are removed so it just acts as a template.

I'm curious as to why you included what the pt's home looks like unless it was cluttered enough (think hoarder) to interfere with any treatments or posed a risk to either you or the pt, or you noticed any drug paraphernalia.

It's good scene description as well as potential information for self neglect cases if the situation calls for intervention at a later date... Just gives you a record documented that states the scene is not suitable for kids, dependent adults etc if there is cause for such info at a later date. It also gives you a trail if a patient say progresses into a stage where they are no longer capable of caring for themselves or dependent loved one.

Edited June 1, 2012 by Iowa Medic