Documentation

[beaucait]

Copy and paste a narrative here:

I am trying to get better at writing out my narrative and was looking to read someone elses idea of a good narrative. As far as some verbiage or transitions from one topic to another go, I am just terrible

I currently use CHART. Maine really likes soap and CHART

 

[akflightmedic]

I look forward to the days when we begin charting by exception as opposed to the current system of "if you didn't chart it, it didn't exist..." mentality. I say this in relation to assessment, not procedures or interventions. We always have to be the ones who lag in healthcare standards.

Anyways, who ya working for? United? You SoPo, MidCoast, Inland?

 

[DrParasite]

For a medical:

U/A, EMS found patient (in what position or with what agency), AOx3 (or as appropriate), CC (whatever chief complaint is). pt also C/O (and other complaints). Pt says (events leading up to complaint and calling 911). Pt attempted (insert what patient took to fix it) with no/little improvement. Physical exam: HEENT=normal or list abnormalities, neck= -TD/-JVD. chest= clear bilat (or better response). abd=SNT (or as appropriate). pelvis=stable. Ext x4 = +CMS (or as appropriate).

list interventions given and patient's response (no change, improved, got worse)

assisted to cot, moved to stairchair, carried out in reeves, M+T to ER, TOT Rn with report given.

meds they are on don't go in my narrative unless they are especially relevant. Ditto history. and allergies. they get documented elsewhere on the PCR. I might throw in my OPQRST depending on the patient complaint, but the above is pretty much my basic narrative in a nutshell. Of course, more complicated patients might include more stuff related to the particular complaint, but you get the general idea.

I'm not a huge fan of CHART or SOAP, because I don't think that way, and if I need to defend my actions, or explain myself to an authoritative person, I want my chart to be documented as such. I have had agencies and QA people who disagreed, but we tend to agree that as long as my narratives have all the information they are looking for, they leave me alone.

I've done QA, and have read too many horrible narratives, even ones that did use SOAP and CHARTE. and I don't believe in the "if you didn't chart it, it didn't exist... " either; I might throw in some pertinent negatives, but in general, you can definitely write too much on an EMS chart.