naritive writting, PCR

[AzEMT]

Hi , I would like to get some ideas, and feed back about how you write your narrative on your PCR or PR ? also doing telemetry? Do you have a certain system or mnemonic that you go by ?

[Sir Hunter~Royal Medic]

you want help with what ???

[Ridryder 911]

If your talking about patient care reports or charting ...a lot of people use the SOAP method and have designed call sheets to match their state requirements for Q.I.

As far as telemetry, I have not used that since mid-70's.

Be safe,

Ridryder 911

[emsgirl]

Hi , I would like to get some ideas, and feed back about how you write your narrative on your PCR or PR ? also doing telemetry? Do you have a certain system or mnemonic that you go by ?

By telemetry are you actually trying to ask for a format for giveing radio reports to the hospital (HEAR reports) to let them know what you bringing?

[1aCe3]

By telemetry, I think* she may be talking about recieving online orders?

[AzEMT]

sorry guys Ive been working and hadn't checked my pc,

I mean doing telemetry or two way radio to the receiving hospital, a list of the info they want on the patient.

PRC= patient care report,,,PR= patient refusal,, everybody has there own style for the narrative,How do you do yours ?

[rsqmedic]

The most common way that I have used in report writing is state how you found the patient, their chief complaint and any pertinent negatives such as no SOB or no chest pain, no pedal edema or JVD. then state history allergies and meds. then any interventions you did and their results. we have check boxes for most of the other info including EKG, pupils, lung sounds and skin signs. As far as orders or "Telemetry" goes I usually write them above the perforation on the form so I don't forget, then I document them on the form as I administer the drug or other therapy.

Hope that's what you needed.....

[emt322632]

I like mixing up my PCR with a little "narrative/report". I like telling the "story" of the patient's present complaint, but also put in report type things.

Ex:

Subjective Assessment

Upon arrival found pt. in X position c/o Y. Pt. stated etc etc.

Objective Assessment

Pt. has a patent airway (or non-patent). Pt. has += chest rise w/ clr. L.S. bilat. (or whatever you find) Pt. is not bleeding.(or whatever you find)

I find this way works very well for me. I have yet to get a PCR back in my 1 1/2 years of doing this.

As for radio reports, I usually just state the chief complaint, anything pertinent to the present injury/illness (i.e. wheezing if S.O.B.) Also vital signs, ETA, any interventions done by you or the patient, did the interventions help? Pain scale if any pain at all...

I think that's pretty much it, hope it helps:)

[lemonlimeEMT]

Writing narratives for PCRs was something I struggled with, hell it's something I still struggle with from time to time. The best advice the paramedics I worked with gave me was to "paint a story", you are the eyes and ears for the ED, you see what they can't, so you have to tell them everything. Let them know as much about the patient as possible; tell where/how you found the pt, condition and complaint of pt, history and allergies, vitals and pertinent findings, treatment, and how the patient responded to treatment. Put enough info so that the ED knows what was going on, but watch out because you can put too much (don't put meaningless information and remember that there are check boxes for findings and such on the front-or at least with ours).

[noahmedic]

This may be way more than what you wanted, but hope it helps! I can't take complete credit for the following I learned it from my Basic instructor and still use it.

Since we use paperless charting I've learned to shorten my narrative section down quite a bit but it is still the most important part of charting. I use the CHART-E method as follows:

C-Chief Complaint This is why you are there at the patients side, i.e., chest pain, SOB, MVA, gunshot wound L knee, etc.

H-History of Present Illness This is a brief, but complete description of the chief complaint...OPQx3RST for pain, pertinent questions for medical, respiratory, etc. Then, pertinent negatives.

A-Assessment From head to toe, broken down into the following sections:

General - Age, sex, approx. weight, level of distress, level of

consciousness and orientation. Visible trauma, approx. blood loss.

HEENT(Head, Ears, Eyes, Nose, Throat)

Chest and Thorax

Abdomen and Pelvis

Extremities and posterior

R-Rx or Treatment

T-Transport In addition to what happened during transport i put Med Control orders here, and transfer of care information here.

E-Exceptions Any deviations from protocol and why, this is also where I document patient refusals, or any communication troubles with dispatch or hospital, or any other problems

For radio reports(I had to sit down and think about the order i say things in) I tend to use the following info, I don't really have a mnemonic for this one:

1)Unit Identification

2)E.T.A.

3)Patients age and sex

4)Chief Complaint

5)Brief(very brief) pertinent history of present illness

6)Major past illness/history

7)Mental status

8)Baseline vitals

9)pertinent finding of exam

10)Emergency care given

11)Patients response to care given

12)Questions for medical control