Full Arrest Narrative

[Dominion]

I tend to use ACHARTE in my narrative style except I tend to do it in this order:

Arrival
Chief Complaint
History of complaint
Assessment
Transport
R - Treatment
Exceptions

Sooo ACHATRE...sounds like it could be french

 

[1badassEMT-I]

It's funny, but the stuff that comes back to bite you on the @ss is the simple stuff. Forgetting to document that you put the rails up on the bed after you transfered the patient. Forgetting to note that you secured the safety straps on the stretcher. Little stuff, like the name of the nurse you transfered care to. Poor spelling. Poor grammar. That stuff really comes back to get you and can make you look like an IDIOT. If all of your PCRs have the same standard format and you make note of the same CYA stuff, your narrative becomes much more defendable when you get called into a deposition or have to appear in court. "Yes sir, I always secure all of the staps on the backboard and make note of it on each PCR that I write..."

You've got to remember that each PCR is a threefold document. It not only must to paint a pre hospital picture of the patient and surroundings, it also has to prove that your provided competent, correct care and it's got to be accurate and correct for billing.

And even though your class document isn't a real "legal document", you should treat it as one. Get in the habit of writing a FULL and complete narrative. Trust me. Go to court once and all of your PCRs will immediately become more legible and MUCH more complete. You'll never look at a report the same way again

You speak the truth.....go to court ONE time and let the DAor Defense attorney rip that PCR to hell and back you will think twice about how you write the PCR.....