PCR Narrative writing skills

[bassnmedic]

I tend to use the SOAP method and I won't repeat what has already been said other than if you don't write it ..it didn't happen. In other words write down every thing the patient tells you, what the family or witnesses tell you, then everything you find positive findings as well as negative , your assessment or differential diagnosis, then finally write what treatments you provided and the outcome or result of thoses treatents. Basically, the more you write them the better you will get, that's the best I can offer from my 18 yrs on the street.

[AZParamedic]

What's this D-CHARTE style of report writing all about?

I've used SOAP notes in the military and tend to write my PCRs now in a narrative with SOAP-like attributes.

Here in New Mex all the locals like to write using this technique. Does anyone else?

D-Dispatch

C-Chief Complaint

H-prior History

A-Assessment

R- (Rx) tReatment plan

T-Transport disposition

E-Exceptional Information

[Dustdevil]

That totally omits the physical examination.

That can't be a good thing. :?

[AZParamedic]

That totally omits the physical examination.

That can't be a good thing. :?

I think the A (assessment) is to include the physical exam?

I don't like it since it to take up too much space on preprinted PCRs that have a small narritive. The D, C, and T are often duplicious on a preprinted PCR too.

Anyone still have checkboxes for the physical exam that indicate "WNL" or "no clinical findings" next to each area of the body?

[Dustdevil]

I think the A (assessment) is to include the physical exam?

That's what I thought at first, but that would mean the PE and the Dx would be in the same block, which is tres confusing.

Yeah, I'm with you. I don't like it.

SOAP remains the best format I have ever encountered. Although, I changed it to HEAT at one service where I designed the PCR.

• istory

Examination

Assessment

Treatment

• "Plan" just doesn't quite work in the field where we will always have already done everything before we get around to charting. And "History" and "Treatment" keeps us from having to explain the difference between subjective and objective to the mental midgets coming out of EMT schools these days.

[fireflymedic]

Thing to remember on PCR's is write everyone like you are going to court. Just 'cause you remember it now, doesn't mean you'll remember it 2 years and a thousand patients later. Here's format I use.

Unit (who I am)

Dispatch (what did they send me out for)

Arrival (how did I find them-sitting, laying, etc)

Who else was on scene (if applicable fire, police, rescue squad, etc)

Damage to vehicle, scene, extrication time (if applicable)

Chief Complaint (what they say their problem is)

Physical Exam (I list each area airway, skin, heent, pupils, chest, lungs, back, abdomen, pelvis, extremities)

Vitals (BP, pulse, respiratory rate - quality I list in lungs)

Treatment (what I did for 'em)

How we got the patient to the stretcher (walked, stair chair, stretcher, etc)

Continuing Assessment (updates to condition, vitals, any other pertinent info)

Where we took 'em (hospital, nursing home, home)

Who we transferred care to (ER staff, ICU staff, etc)

If they had any further complaints addressed prior to delivery to ER (usually is no, 'cause you address that enroute)

Medications (if multiple, I write multiple meds-see attatched list-make sure you attatch the list ! )

Past Medical History (only that which is pertinent)

'

I've followed this format most of my career and it's served me well. Never gotten QA'd for lack of information and always recieved good response for writing complete reports. Hope this helps you some. Works universally for all run sheets and departments too.

[JPINFV]

Just wondering, is most people's PCR a narrative? The PCR's at my company only devotes less then 1/6th of the space to the narrative. I would think that a lot of what other people are putting in their narrative would be found elsewhere. For example the subjective part would be in the hx, allergies, meds boxes. The assessment would go, respectively, in the V/S, picture, primary survey (ABC, skins, LOC, pupils, and lung sounds each have their respective area with choices to check) and the secondary survey?

I would, though, like more space for my narratives...

[JakeEMTP]

We use the Electronic PCR's in Pitt county. Our particular model is the Toughbook. As, most of you are aware it is a series of check boxes and drop downs ( I know Dustdevil hates these, progress I guess ). The good think about it is once we are in the EMS room at the ED, there is virtually and endless space to write a narrative. All relative information is placed here. I personally like this as I feel a lot more comfortable explaining the call in my own words.

Be safe out there.

[fireflymedic]

We use the electronic as well, but the drop downs don't allow you to really state what is going on, so we have a space where we can add to the narrative, or allow the computer to generate one based on what we have written. I usually choose to write my own (just personal preference) especially in traumas or complicated cases. Basic transfers I'll let the comp do the work. We have the hammerheads and I love 'em. Only problem we run into is keeping them charged for a full 24 shift. We have to plug them into the inverters on our trucks. Very convenient though. I like 'em. I've used state forms (which I hate, they suck), special order forms the service ordered (those were actually okay) which we used until they went to the electronic which I prefer to any of it. Good times. All a matter of preference.

[JakeEMTP]

We use the electronic as well, but the drop downs don't allow you to really state what is going on, so we have a space where we can add to the narrative, or allow the computer to generate one based on what we have written. I usually

Isn't that what I said? I agree, I never use the computer generated narrative. It doesn't have the ability to say anything you noticed or what the pt. told you. A stupid feature that should be banned.