Taking patient assessment notes during exam

[rhan101277]

How do you do it? I have seen people write on gloves, which our instructor doesn't recommend. I tried some tape on my pants, but many many folks in EMS use gloves. Someone also told me you can recall stuff really well and go from memory.

I just want to see how others did this.

 

[Veneficus]

How do you do it? I have seen people write on gloves, which our instructor doesn't recommend. I tried some tape on my pants, but many many folks in EMS use gloves. Someone also told me you can recall stuff really well and go from memory.

I just want to see how others did this.

If there is only one patient, I usually just remember it.

If there are more than a handful I use 2" cloth tape and tear a piece for each patient about 10 inches long, that way as I do more vitals, etc, I can just write it on the tape. If I will be seperated from the pt. (by another provider coming to care for them or when I finally deliver them, I stick the tape on the pt after I copy the info I need)

 

[Shishkabob]

I tend to be able to recall most info, but if it's not a real pt there isn't much wrong with doing it on your glove. Some will say that's starting a bad habit, but so ling as you can differentiate between real and fake, who cares.

Could always use a pocket notebook or even tear tge paper out and tape it on your pants.

 

[41 Duck]

IF I've _really_ got to write something down, it doesn't matter much to me what it's written down on. Notepad, back of a 4x4 package, tape, back of the monitor strip... I generally don't use my gloves because I tend to be on autopilot a lot of the time and throw them out, thereby tossing needed information--but that's just me...

Later!

--Coop

 

[CollegeBoy]

The good majority of my work is first responder through a fire department, so I will alot of times write the vitals on my glove, then when the ambulance gets on scene I will toss them my glove (if its clean obviously) and put on a new one. My report doesnt require a set of vitals, only the ambulance's.

 

[VentMedic]

Tape or notepad is best if you can not remember things very well.

Writing on the glove is a dangerous practice since you can easily cause small punctures in it which puts you at risk.

 

[rhan101277]

I think I will try to get better at the 2" tape method. I bought a fine tip sharpie to write on it with, but my leg doesn't make a good table because sometimes I am standing up and need to write something down and it makes me feel stupid to have to bend down.

I will get the hang of it sooner or later. Its easy to take notes inside the ambulance but when you find yourself at a pts home it gets a little more difficult and I want to be accurate.

 

[Veneficus]

the nice thing about tape is you can move it.

If you are standing put it on your sleeve (the opposite one than you write with) in the truck switch it to your leg.

 

[downunderwunda]

Writing on your glove can, as vent stated, be an infection control risk, aside from punctures, we use golves to protect us from primarily body fluids. Body fluids carry all sorts of nasties, if you manage to not puncture you glove, you have still touched the pt. Then, at some point you have to transfer the data from you glove to youe PHCR, so you will transfer any infection across.......


Do we really need an infection control lesson or can we end this here with a little bit of common sense?

 

[rhan101277]

the nice thing about tape is you can move it.

If you are standing put it on your sleeve (the opposite one than you write with) in the truck switch it to your leg.

This works great during the fall or whenever I wear a long sleeve shirt. I guess I could also put it on the underside of my bare arm.

To downunda, I don't need a lesson thanks. Just trying to see how other people approach this.

 

[NomadicMedic]

I've found I really like to take notes... it helps me organize my thoughts and when I look at them I can see if I missed something.

I usually keep a small bunch of 3x5 index cards in my pocket. When I start my PT interviews, I just pull 'em out and start jotting down notes.

It helps me, and I don't look like a doofus with a big strip of tape on my pants.

 

[boingo]

3x5's. I don't take notes per se, more like write down meds, demographics, vitals. I tend to remember the interview and exam without writing it down.

 

[wyoskibum]

How do you do it? I have seen people write on gloves, which our instructor doesn't recommend. I tried some tape on my pants, but many many folks in EMS use gloves. Someone also told me you can recall stuff really well and go from memory.

I just want to see how others did this.

At my age, if I don't write it down, I don't remember it!! ;-D

I've used the tape method for years and it works well for me. If I get back2back runs, I paste it on a piece of paper to save it for later. If you can get it, the 3" cloth tape works the best.

 

[Dominion]

I personally try not to use my gloves as I get absent minded and toss them. I usually write all my notes on my run form in a space that we don't use. Normally we write meds, allergies, and other medical conditions not listed in the 'generic' history section. If I have room it goes there, if I don't have room I try the sheet if we're in the truck, or tape on the pants. My service (for some weird reason) doesn't buy 2 or 3inch cloth tape, so I have a roll I bought myself that I use when I do the tape. It is really useful, when you're done take it off pants and put it on patient or the stretcher. Great for giving report as I usually will write their name, DOB, c/c and findings from my exam down in a bullet format so that I can give a more concise report to the nurse. Works well for me and I can leave that with the patient.

 

[trevor1189]

Notes definitely help me with my assessment. More so with detailed than a quick quick one. I usually try to have a pad nearby to write things down, but I have used my glove or my hand when I find myself without one.