naritive writting, PCR

[Ace844]

Hi All,

I would like to share my method to documentation. I didn't learn to do this properly until I had been in EMS for awhile and I wished that I had learned this alot quicker. DISCLAIMER: THIS METHOD IS ONE WHICH I USE YOUR MILAGE MAY VARY. Ok, this method as I will describe it is a modified version of the Simplified EMS Method/story method. This method is abit tedious, but alas I submit for your consideration that DOCUMENTATION is a VITAL/CRITICAL area of patient care and can vastly effect you and your patient. Don't be afraid to write an extensive, thorough, conscientious report!!!! 8)

I was taught this by a conscientious Medic whose wife was a medical litigation attorney and have modified it abit to fit my own uses/prejudices/work best for me. Which I am sure that you will do as well. A major principle of this method is that "ANYONE" reading your report should have an idea of who, what, when where, why, etc.., and how the call, scene, patient, CC, etc.. presented to you and why you made the treatment/transport decisions, etc....

1.) Dispatched to, and why, units responding.

2.) How the scene patient presents/found/ info provided to you by others (i.e.: bystander, other providers, pd, dispatch, etc...)

3.) Age, Sex, (if appropriate Race)

4.) If not otherwise listed PCP or RX MD

5.) Chief complaint, objective/subjective, etc..

6.) Assessment, head to toe, with all +@- findings. Be sure to show that you "considered, and Ruled out" all Life Threats/Major medical disorders.

7.) Vitals

8.) known Meds/allergies.

9.) EMS Treatments and pre/post assessment-responses to it if any.

10.) Changes during TX/acuity/other levels of providers involved in care

11.) Rendering of care and report and to whom.

So here is a quick basic overview of a very thorough way to document a run form. Hope this helps.

Ace

[Ace844]

hello everyone,

Here's a link which has some great information on this subject::

http://whqlibdoc.who.int/publications/2005...9294X_chap6.pdf

Here are some other realted threads on this site::

http://www.emtcity.com/phpBB2/viewtopic.php?t=4431

http://www.emtcity.com/phpBB2/viewtopic.php?t=3563

http://www.emtcity.com/phpBB2/viewtopic.php?t=2414

http://www.emtcity.com/phpBB2/viewtopic.php?t=353

http://www.emtcity.com/phpBB2/viewtopic.php?t=1069

http://www.emtcity.com/phpBB2/viewtopic.php?t=561

http://www.emtcity.com/phpBB2/viewtopic.php?t=3560

Hope this Helps,

ACE844

[medic001918]

I use the same format for just about every PCR that I write. By using a set system, I find that I don't leave things out and it can help with performing an assessment should you ever find yourself stuck.

Example:

Called priority _ to above location for pt 28 y/o male restrainted driver involved in two car, head on style MVC. Vehicle with heavy front end damage. + Airbag deployment, - Steering wheel/dash deformity, - windshield intact, ? Loss of conciousness. Upon arrival found pt sitting in drivers seat a/o x 3/4 (confusion of event), + ABC, GCS=14 (4/4/6), PERRLA, skin warm/dry, + Headache, + Dizziness, + laceration approx 1/2" long above left temple, + neck pain @ midline, - JVD, - Trach dev, + chest pain 5/10 that increases w/respiration and palpation, - SOB, - increased work of breathing, lung sounds clear and equal bilaterally, abd soft w/tenderness at RUQ, + nausea/-vomit, + R flank pain, + back pain, hips/pelvis stable, + PMS X 4, Neuro assessment w/o deficit, - extremity injury x 4. Pt placed in manual c-spine stabilization --> c-collar --> LSB --> CID. + PMS x 4 before and after immobilization. LSB --> Stretcher --> Ambulance. v/s as noted below. Pt on O2 @ 15 LPM NRB. IV established, 18 gage NSS @ KVO L AC. EKG = Sinus Tach w/o ectopy. During transport pt with short term memory loss and repetitive questioning of "what happened to me?" Pt transported priority one to ABC Medical Center without change or incident. Transfer care with report to RN and/or MD.

*I think I got most everything. It's hard to write a narrative on a call you just made up.*

Most of what I write is also checked off in the check boxes of our run forms. Our blood glucose gets written in a specific location, so I don't usually write it in the narrative, along with the vitals. By using the same format, you're less likely to forget something in your assessment or your report.

Shane

NREMT-P

[Rezq304]

I'm with Noah on this one. For 95% of my PCR's I use the CHART method. The only exception that I make to that is if I come across a run that is just WAY out of the ordinary and would be extremely difficult to fully "paint the picture" in that format.

[chbare]

I have always used the SOAPE or POMR method of charting. This comes from my military days and perhaps it is a little bit of the old dog not learning new tricks situation. This is a basic rundown of how I use the POMR/SOAPE charting method.

S=Subjective information

-Chief complaint

-Dispatch info

-Patient history

-OPQRST

-Symptoms

O=Objective information

-Vital signs

-Physical exam findings

-Signs

-Results of tests

A=Assessment

-My working diagnosis (what I think is wrong)

P=Plan

-My interventions on scene and enroute

-Transfer of care

-Discharge and follow up instructions in the non EMS environment

E=Evaluation

-How the patient responds to my treatment

-Follow up care in the non EMS environment

Sorry for any spelling errors, spell check is not working.

Take care,

chbare.

[Just Plain Ruff]

I take a different slant on reporting. You find a format that works for you and never deviate from that format. If you consistently do it one way and never deviate from it you will become a very good report writer. It just takes time.

Second, I had a book that told you how to write a legally defensible report. I cannot remember the book but it opened my eyes

[medic001918]

I believe the book is called The Missing Protocol and they have a website. www.themissingprotocol.com I have read the book, and while being a dry read there is some good information to be had in it.

Shane

NREMT-P