Narrative tips

[Bdumaine]

I've been an EMT basic for a little over a year now and I'm quite happy with my job. And im always trying to improve how I interact with patients and how I do my paperwork.

The company I work with now does mostly interfacilty transports. We take a patient from the hospital back to wherever. 

The narratives for the calls are pretty stright forward. But I wanted to see if any of you guys might be able to look at what one of my general narratives looks like and maybe give me some advice on what might make it better.

Here is a basic narrative for a call going from a hospital to a SNF. 

On scene PT found in medical be with rails in upright position, PT in hospital for shortness of breath and being discharged via bls because PT is on oxygen. PT assessed and vital signs found to be WNL (or not WNL) PT assessment found PT has Foley catheter and is on oxygen via NC@2 lpm. PT transferred to stretcher via Morrison soft stretcher and secured via 5x straps. PT loaded into unit and reassessed, VS trending WNL. Enroute to destination PT remained stable with no negative downtrending. At destination PT offloaded and transferred to facility medical bed via Morrison soft stretcher. On staff RN accepted patient care and signed for transportation.

That is a normal PCR for me, it of course isn't always the same but you get the idea. Is there anything else I could do to make my reports any better? Any and all advice is welcome.

[Just Plain Ruff]

be careful with your WNL's,  make sure you have somewhere in your policies or procedures that you have normals listed.  

Also, make sure that with your statements in trending, how many vital signs are you taking to make a trend?  If you are only taking 2, then you don't have a trend.  If you are taking 3, thats a little better, but if you have 4 or 5 that's even better.  But for a simple transfer to a SNF, you really don't need to talk about trending.  

Plus be careful with your abbreviations.  PT of course to you means Patient but to someone else it might mean Physical Therapy or something else.  

I also don't see any full body assessment of the patient. You have a patient on oxygen yet no lung sounds.  Of course that might be somewhere else in a check box or something like that.  I'm just seeing your narrative.