Report Writing (Documenting Rx)

[BecomingaBetterEMT]

I use saying keep it simple stupid, KISS. Obviously anything out of the ordinary a would make not of but really saying that you secure the pt with straps is unnesscary.

 

[RefriedEMT]

I still use what I learned in the class and my first ems company. SOAP Subjective, Objective, Assessment, Plan and I write my report in that order. Essentially just write what the PT and bystanders told you, what you saw and did, a few possibilities that need to be ruled out such as CHF in a chest PX call and then I just write every intervention that I performed (plan) during the call such as administering O2 with NC or NRB. So pretty much just what the guy above me said, keep it simple. You would not believe how simple some EMTs i've seen write their reports, it made me think it was always extremely quick and easy but you just gotta work at it and you get faster and faster writing these reports. I started out taking more than 10mins to write a full report, after a while I could get one done in 4-5mins, the city will force you to get better and faster because I can still remember my FTO telling me we had 911 calls waiting in our area and freaked out and wrote like a damn tornado.

 

[Akulahawk]

I have used a few different methods of writing my narrative... mostly I used a variation of SOAPIE. I don't do a ROS as you'd find in an H&P so that makes things a bit shorter to write. While I don't double chart certain things, I will reference data that is listed elsewhere if it's pertinent. My assessment is basically my field diagnosis and is therefore what I'm basing my treatment plan on. I usually then list my interventions actually done and then evaluate the response to those interventions and repeat the cycle.

Usually then I'll end the report with a disposition of the patient and who I turned the patient over to.

Done right, writing this only takes a few minutes. The downside of this method is that you might chart too much detail leaving the pertinent stuff (pos and neg) in the weeds. It's also very easy to double chart stuff using this method and while that's not a bad thing, it takes up space you might use for something else, and you could chart the same item differently which could call your entire report into question. After all, if you goofed on one thing, perhaps you goofed on other stuff...

 

[Carlos Danger]

Excellent post, @akflightmedic