Patient care reports

[MariB]

Interesting to see how different people write out reports and great to pick up some tips and tricks from other.. My version of this is:

"History of fall off bicycle at slow speed landing on R) knee. Ambulance called,

O/A: pt supine on footpath -> conscious & alert ->good colour -> in obvious distress

O/E: primary survey clear. Secondary survey reveals R) knee injury with nil signs of knee or patella dislocation or obvious fracture. Redness and swelling present. Pt very distressed with knee examination. Unable to determine FROM. ? soft tissue injury. Pain 5/10. Splint applied. Pt has nil other injuries. C-spine cleared. Pt has full recall of events and nil neurological deficits. Nil pmhx.

E/R: pt pain decreased with pain relief and reassurance and pt become more relaxed. Nil change in pt condition.

Meds: Nil

Allergies: NKDA"

I think I should spend more time on writing out reports. This was an example of our usual. I didn't need to add pain scale, allergies, meds given etc because our software again has a place for that. Once printed, it comdd out so nice an organized. Quite dummy proof. Which is good as I am very new.. very

[scubanurse]

One of the purposes of narratives is if in 2 years the case goes to court, you can re-read the narrative and remember all of the things you did on the call. At least that's always what I've seen them for.

[HarryM]

MariB am jealous that you guys are electronic! We are getting it in the next year or two and cannot wait! Do you print it out and give it to the receiving facility or email it directly to them?

[MariB]

One of the purposes of narratives is if in 2 years the case goes to court, you can re-read the narrative and remember all of the things you did on the call. At least that's always what I've seen them for.

yea, that is what I figure too.

MariB am jealous that you guys are electronic! We are getting it in the next year or two and cannot wait! Do you print it out and give it to the receiving facility or email it directly to them?

it is nifty. We start out entering patients name address etc. Click next, put in vitals, it guides you through left lung sounds, right lung sounds, left pupil, right pupil, skin, gcs, bsl , if you didn't do it, you click not done, if you did it has all the options.

Paramedic level for meds, everything from time dispatched to EMT impression is on there. Every box has a place for comment. If I click I did a blood sugar I put the glucose level in comments.

The only place to use our brain at all is the narrative. And we don't have to mention the signs and symptoms, pain scale, allergies or anything since we went through and did all that already in the assessment part of the software. When we print it out, it prints out extremely professional and in order.

I could look at it and see every thing on the first page in 5 years and know what call it was.

We print and then fax since our software may not be compatible

[musicislife]

Ok. In my agency we use paper. I suppose my narrative for a 20 y/o f with ab. pain.

Bls 208 dispatched 911 for 20 y/o f. with ab pain. Upon arrival found pt in fetal position on couch being attended to and given 02 by po on scene. Pt stated "severe" pain in ab. Lung sounds assessed. Cap refill assessed. Skin color temp condition assessed. Perfusion appears normal. Focused assessment revealed 10/10 cramping pain in LLQ ab. PT states regular menstural cycle and no possibility of pregnancy. Hx and vitals assessed. Assisted pt to stretcher+secured w/ straps x3. Loaded pt into ambulance. Removed po's O2 and connected pt to main. Transported to valley ER. Pt re assessed en route and found no further problems. No noticed change in condition en route. Handed to nurse Kristen at valley ED. Assisted to pt to bed 2B. Returned to service.

What do you guys think?

[Just Plain Ruff]

Yes, the reason for reports is not for the hospital nor for the patient. It's for two reasons.

1. for the patients attorney when they come back to sue you for a perceived or actual wrong, they can look to see if you did something wrong or left something out. They want to see if there is something that they go after you personally in your report.

2. They are for you to look back on to refresh your memory and maybe help save YOUR ass in that court room when that attorney from number 1 is trying to take away your livelihood and your family support. Writing a report that will save your livelihood and your financial future, isn't that worth the effort in investing the time it takes to perform proper grammar, proper sentence structure and spelling things out right. To keep from using unapproved abbreviations and shorthand. To keep in the back of your mind this simple sentence, "If you didn't write it down, YOU DID NOT DO IT!!!!!!!!!!!!!" You cannot add to your report in court. If you add to the report in court the plaintiff's attorney will brand you a liar. If you have terrible spelling or grammar the plaintiff's attorney will brand you a terrible provider.

Remember, first impressions (your trip ticket) are impossible to change.

[musicislife]

We use the DCHART format:

D: Dispatch information

C: Chief complaint

H: History (SAMPLE & OPQRST)

A: Assessment: Physical exam, Labs & Vital Signs

R: Rx: Treatment rendered and patient response

T: Significant notes during transport

Field impression at the end

I have copied a fairly recent PCR that I did with some of the data removed or changed for obvious reasons:

D: Dispatched to the scene of a 76 year old male or female with weakness

C: 84 y/o male or female found sitting in chair at home with family at his/her side, pt reports “I think I feel alright,” family reports he/she has been very weak and breathing fast and they cannot get him/her out of his/her chair to get into the car to take him/her to the hospital, Pt contact made at 09:50

H: S: generalized weakness, tachypnoea

A: NKA/NKDA

M: Jalyn 0.5 mg PO q D, Megase oral PO Q day, mirtazapine 7.5 mg PO Q day, tamsuiosin 0.4 mg PO Q HS, temazepam 30 mg PO Q HS, Trazadone 50 mg PO Q HS, hydrocodone/APAP 5/325 PO PRN, lisinopril 1.25 mg PO Q D

PmHx: HTN, BPH, Fall resulting in intracranial haemorrhage in December 2012

L: Last HS

E: Family reports that the patient has recently been discharged from rehab following a fall resulting in a TBI but has been progressively weak and unable to perform ADS’s with s/s that have worsened over the past couple of days

O: Last HS

P: Denies pain or discomfort

Q: Denies pain or discomfort

R: Denies pain or discomfort

S: Denies pain or discomfort

T: As defined above

A: HEENT: Sitting upright in chair, AO times 4 with movement in all extremities, atraumatic to exam, airway patent and self maintained with increased respiratory rate, pupils pinpoint and minimally reactive bilaterally, neck midline with flat jugular veins, Pt able to swallow without difficulty and smile w/o indication of facial droop, speech slow but non-slurred

Cx: Atraumatic, unlaboured respirations, no accessory muscle use, clear lung sounds in all lobes, no c/o dyspnoea, no overt s/s of respiratory distress, but rapid and deep respirations at a rate of 24 noted with regular rhythm, irregular, faint heart tones noted at an elevated rate of 112-118, firm, round mass with a diameter of approximately 5 cm noted to lower right anterior chest wall, Pt reports “I have had that forever”

Abd: Soft all quadrants, non tender to palpate, atraumatic to exam

Pelvis/GU: Pelvis stable and intact, full GU exam deferred, Pt reports that he/she has been having “difficulty going pee”

Ext: Movement in all extremities with weak bilateral hand-grips, atraumatic to exam, pale/cool/dry skin with decreased turgor, no indications of cyanosis or jaundice noted

Neck/Back: Atraumatic, midline w/o step offs, Pt denies any c/o

V/S: B/P- 60/40, P-118 & irregular, RR- 24 w/o overt indications of significant respiratory distress, SpO2-88% R/A, T-98 F, Wt~68 kg, Temp 97.1 F tympanic

Rx: 1) Pt contact and full assessment, placed on portable pulse oximeter and BGL of 265 mg/dl noted, Pt placed on supplemental Oxygen at 2 L/min via nasal cannula @ 09:50

2) Pt carried out of his/her room and down a small hallway via transfer sheet and placed onto the EMS str into semi Fowlers position by EMS crew, Pt reports “feeling like I’m going to faint” upon being picked up, Pt properly secured onto EMS str w/o incident @ 09:55

3) Loaded and properly secured in EMS unit for transport w/o incident, Placed on monitor for continuous SPO2 monitoring and cardiac monitoring in lead II with q 5 min v/s reassessments and XII lead acquisition and transmission to General Hospital ER w/o incident, sinus tachycardia with frequent unifocal PVC’s w/o overt ST changes or indications of BBB noted @ 10:00

4) 20 ga IV placed to L AC times one attempt using aseptic technique w/o incident along with BGL check (123 mg/dl), fluids up at 1,000 ml 0.9% NS at wide open rate for volume expansion @ 10:02

5) Radio report called to General Hospital ER w/o incident @ 10:05

6) Discussed possibility of Zofran administration for c/o nausea with EMS preceptor; however, she/he does not want to administer it at this time d/t "short ETA to the hospital", Repeat VS reassessment @ 10:10: B/P- 72/40, RR-22-24 and non-laboured, SPO2-96% 2 L NC, P-112 irregular, lung sounds remain clear after 500 ml of fluids have been administered, 1,000 ml challenge continued

T: Pt transported to General Hospital ER w/o incident or change in assessment or condition, bedside report and turnover to Dr Smith w/o incident @ 10:15

DDx:

1) Hypotension with possible tissue hypoperfusion

a) Possible infectious pathology (Consider urinary and respiratory sources as high priority systems to assess)

Possible toxicological etiology (Consider opiate toxicity with possible poly-pharmacy as a primary candidate)

2) Cannot rule out neurological event (TIA vs Stroke with possible increased ICP or intracranial mass effect)

3) Possible fluid volume deficit

4) Hypoxaemia with possible tissue hypoxia

5) Hypoglycaemia R/O with point of care BGL testing

Please note this may be based on a patient encounter but it is not an actual chart and presented here as a training tool.

you put that all in the narritive section? Our reports look something like this http://www.docstoc.com/docs/41480699/GENERIC-RUN-REPORT-Prehospital-Patient-Care-Chart-GENERIC-RUN-REPORT-Prehospital i dont have an actual blank one from my squad to scan in at the moment. However, this system looks pretty good

[scubanurse]

Ok. In my agency we use paper. I suppose my narrative for a 20 y/o f with ab. pain.

Bls 208 dispatched 911 for 20 y/o f. with ab (1) pain. Upon arrival found pt in fetal position on couch being attended to and given 02 by po (2) on scene. Pt stated "severe" pain in ab. Lung sounds assessed. Cap refill assessed. Skin color temp condition assessed. (3) Perfusion appears normal. Focused assessment revealed 10/10 cramping pain in LLQ ab. PT states regular menstural cycle and no possibility of pregnancy. (4) Hx and vitals assessed. (5) Assisted pt to stretcher+secured w/ straps x3. Loaded pt into ambulance. Removed po's O2 and connected pt to main. (6) Transported to valley ER (7). Pt re assessed en route and found no further problems. No noticed change in condition en route. Handed to nurse Kristen at valley ED. Assisted to pt to bed 2B. Returned to service.

What do you guys think?

1) Ab is not a universal abbreviation for abdomen. You should never use abbreviations in your narrative unless they are on an approved list by your agency and even then it is a huge risk to take.

2) O2 by po??

3) It's great that lung sounds were assessed but what did you hear? Did you just listen without critically thinking through what they would be classified as? Same with cap refill and skin condition. What did you assess them to be? Writing down that you looked at those things is great, but meaningless as to the condition of the actual patient.

4) If you are going to write patient states, put the statement in quotations.

5) Again, put down the information you gathered from the history and vitals. You're giving half information here and that will get you into trouble.

6) What does that even mean?

7) I would put down the real name of the hospital and use proper grammar with capitalization.

Here's how I would write that report.

C: BLS Unit 208 dispatched to a 20 y/o female c/o abdominal pain. Upon arrival, found patient in fetal position being attended to by (state who was actually there). H: S- symptoms listed here (diaphoretic? flushed? what are YOU observing about the patient). A-allergies M-medications patient is on P- past medical hx, has this happened before? L- last oral intake (pretty important with abdominal pain assessment) E- what was the patient doing leading up to this pain starting? Was she just sitting around? Was she playing football?

A: Review of systems- Skin condition, mental status, location and OPQRST of pain, vital signs, bowel sounds, lung sounds, any data you actually collected should be listed.

R: Oxygen initiated at ____lpm via _____ by _____________(person who actually initiated care). Patient placed onto stretcher for transport in position of comfort. Oxygen continued at ____lpm via _____ with onboard oxygen. Any other treatments/interventions you performed.

T: (Mode of transport) ex. Transported with patient on stretcher, emergent to Valley Emergency Department. Report given to Kristen, RN and patient placed in room 2B.

It is important to be as detailed as possible. Like I said earlier, if you didn't write it, you didn't do it. Just saying you listened to lung sounds is not enough. Any attorney will look at that and say "what were the lung sounds? Did she have bilateral rhonchi that you failed to document and report?" The point of the narrative is to help YOU in the event a call goes to court. In 5 years will you really remember what her lung sounds were? Or her vital signs? Highly doubt it.

Hope this helps!

[musicislife]

1) Ab is not a universal abbreviation for abdomen. You should never use abbreviations in your narrative unless they are on an approved list by your agency and even then it is a huge risk to take.

2) O2 by po??

3) It's great that lung sounds were assessed but what did you hear? Did you just listen without critically thinking through what they would be classified as? Same with cap refill and skin condition. What did you assess them to be? Writing down that you looked at those things is great, but meaningless as to the condition of the actual patient.

4) If you are going to write patient states, put the statement in quotations.

5) Again, put down the information you gathered from the history and vitals. You're giving half information here and that will get you into trouble.

6) What does that even mean?

7) I would put down the real name of the hospital and use proper grammar with capitalization.

Here's how I would write that report.

C: BLS Unit 208 dispatched to a 20 y/o female c/o abdominal pain. Upon arrival, found patient in fetal position being attended to by (state who was actually there). H: S- symptoms listed here (diaphoretic? flushed? what are YOU observing about the patient). A-allergies M-medications patient is on P- past medical hx, has this happened before? L- last oral intake (pretty important with abdominal pain assessment) E- what was the patient doing leading up to this pain starting? Was she just sitting around? Was she playing football?

A: Review of systems- Skin condition, mental status, location and OPQRST of pain, vital signs, bowel sounds, lung sounds, any data you actually collected should be listed.

R: Oxygen initiated at ____lpm via _____ by _____________(person who actually initiated care). Patient placed onto stretcher for transport in position of comfort. Oxygen continued at ____lpm via _____ with onboard oxygen. Any other treatments/interventions you performed.

T: (Mode of transport) ex. Transported with patient on stretcher, emergent to Valley Emergency Department. Report given to Kristen, RN and patient placed in room 2B.

It is important to be as detailed as possible. Like I said earlier, if you didn't write it, you didn't do it. Just saying you listened to lung sounds is not enough. Any attorney will look at that and say "what were the lung sounds? Did she have bilateral rhonchi that you failed to document and report?" The point of the narrative is to help YOU in the event a call goes to court. In 5 years will you really remember what her lung sounds were? Or her vital signs? Highly doubt it.

Hope this helps!

BLS Unit 208 dispatched to a 20 y/o female c/o abdominal pain x 30 min. Upon arrival, found patient in fetal position being attended to by P.O 423. PT diaphoretic, pale. NKA. Meds: Wellbutrin. Regular menstrual period. PT ate plain bagel and drank 1 glass of water 2 hours PTA. PT stated she was watching TV. Skin: Pale, cool, diaphoretic, AAOx4, sharp pain in LLQ, 10/10, denied radiation, constant for 30 min, sudden onset, vital signs assessed(see below), lung clear and equal in all fields, PT denies possibility of pregnancy. Denied again when asked a second time en route. Oxygen initiated at 15 lpm via NRB by P.O 423. Patient placed onto stretcher for transport in position of comfort. Oxygen continued at 15 lpm via NRB with onboard oxygen. No changes en route. Transported with patient on stretcher, emergent to Valley Emergency Department. Report given to Kristen, RN and patient placed in room 2B.

P.O 423 when written on reports in my area means Police Officer then his call sign. PTA means prior to arrival, standard in my squad. How is this?

[scubanurse]

Looks much much better. I would use the letters to help the reader know what information is being provided, like S: Pt diaphoretic, pale A: NKA M: Wellbutrin P: Regular menstrual period (LMP: ______ if you can obtain it), L: plain bagel and water 2 hours PTA, E: Watching TV when pain started....see what I mean? It'll help you as you write them as well to organize it this way.

Consistency in report writing is key. If you write your reports the same way every time, it will become so second nature you won't have to think about it.