# IFT Documentation



## redbull (Jan 5, 2011)

I'm always looking to improve on my documentation for IFT. Unfortunately my EMS class did not teach me much about this other than CYA (Cover your ***). I think doing documentation for a private company is slightly different. 

I find myself not writing enough - If we have a patient we're transporting back home, who has been discharged from the hospital...what else can we write other than "Pt was transported back to home without change in status or incident?", "Positive ABC's", "-JVD", 

Also, documenting in what position the pt was found is important too (for Medicare). But like I said, I'm always looking to see what else I could write. 

1. What else would you write for a transport back to patient residence besides the obvious? 

2. What would you write for an emergency for sepsis (from nursing homes I always inspect the pt prior to putting he/she on my stretcher)? 

3. Dialysis run? 

Thanks!


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## b2dragun (Jan 5, 2011)

When i feel like adding when i have nothing to add i put down pert negatives: pt - CP, SOB,  Abd pain, n/v/d, head/neck/back pain.  

I also can add in: pt condition - change enroute, pt - dcapbtls, pt has no other complqins at this time...stuff like that.


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## redbull (Jan 5, 2011)

b2dragun said:


> When i feel like adding when i have nothing to add i put down pert negatives: pt - CP, SOB,  Abd pain, n/v/d, head/neck/back pain.
> 
> I also can add in: pt condition - change enroute, pt - dcapbtls, pt has no other complqins at this time...stuff like that.



I wrote that alot too but then I imagined myself reading it aloud in court? :sad:
No knocking your response at all, just seeing it from a different perspective>


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## b2dragun (Jan 5, 2011)

I would be happy to read it in court, it means I did a complete assesment.  If a pt is going home then you want to make sure she is ok and feels that way.  When you pick up your pt don't you want to tell the hospital on report whats not wrong with her.  Pertinent negatives can be a good form of documentation.  Saying a pt did not change enroute will document that their problem did not get worse.  It will also say that what you did enroute did not help/harm your pt.  Saying your pt has no other complaints also states that you did an assesment, how many pt's don't tell you about something because they don't think it is relavent.

You say you think about reading it in court, think about reading your chart that has no assesment and only says the pt went home.


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## Aerin-Sol (Jan 5, 2011)

http://emtlife.com/showthread.php?t=20912

This thread had some helpful info.


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## JPINFV (Jan 5, 2011)

redbull said:


> Also, documenting in what position the pt was found is important too (for Medicare). But like I said, I'm always looking to see what else I could write.


Write what you find. Your assessment should be based on your knowledge and the patients condition, not what needs to be documented. 




> 1. What else would you write for a transport back to patient residence besides the obvious?
> 
> 3. Dialysis run?



Patient found A/O x 4 in hospital bed following an admission for ____ and is being transported to ____. Following receiving report, the patient was [assisted/moved via draw sheet] to the gurney. Patient transported in position of comfort with side rails and seat belts. V/S monitored. No change noted during transport. At destination, patient was [assisted/moved via draw sheet]to [bed/wheelchair/ chair] and left in care of [RN, family, etc].

A few quick notes: Allergies, medications history, ABCs, skins, lung sounds, vitals, and a few others are normally check boxes found elsewhere on PCRs. Also, anything abnormal such as coughing can be added easily. 



> 2. What would you write for an emergency for sepsis (from nursing homes I always inspect the pt prior to putting he/she on my stretcher)?



You will most likely need a continuation sheet for this style given the average size of the narrative boxes. Additionally, while the style is somewhat rigid, you can add and subtract from all of the boxes as need be. There's two huge, albeit very related, benefits from this style. SOAP notes are THE STANDARD for documenting a medical history and physical. Any physician should be able to pick up a properly formatted SOAP note and understand exactly what you're saying. Additionally, once you're familiar with the SOAP format, it will make reading the H&P found in patient packets much easier. 

Now, admittedly, not everything is needed for all patients, nor necessarily important depending on the patient's status. I wouldn't necessarily worry about the sexual history in a septic patient, but a female with abdominal pain this becomes important. Similarly, a family history is very important in a patient with chest pain. Another problem is I don't think it's necessarily appropriate for documenting a patient found in cardiac arrest.  

If I was working on an ambulance now, for emergency calls I would use a format that I've termed "P-SOAP-D." The reason for the "D"[elta] is that a prehospital patient care report is essentially a history and physical combined with a progress note. 

Formatting note: This is not in one continuous paragraph. Subject headings are just that. If something is prefaced by an asterisk, then it is its own paragraph. The function of this is to cut up the information so that specific pieces of information can be easily found if it needs to be referenced. 

Prearrivial: 

Unit 75 was dispatched code 3 to XYZ nursing home for a patient with a dispatch complaint of altered mental status. During the response we were delayed at an at-grade railroad crossing for approximately 3 minutes. 

Subject:
*History of present illness (HPI): Patient is a 75 year old male with a chief complaint of an altered mental status. The patient was found unresponsive in his bed approximately 20 minutes ago from nursing staff. According to the RN, the patient developed a fever which was controlled using Tylenol. The patient's temperature last night was ___ and temperature prior to calling us was ___.  [insert rest of current history.  OPQRST goes here. Etc]

*Medical History:

*Surgical History:

*Medication: (include dosing and what for)

*Allergies: (include what the reaction was)

*Family History: 

*Social History: (drugs, alcohol, tobacco, sexual history, occupation, etc as important)

*Review of systems: (questions that you ask)
**General: (e.g. weight gain/loss, dizziness, loss of time, fever, chills)
**HEENT:
**Neck:
**Cardiovascular:
**Resp:
**Abdomen 
**GU
**Extremities
**Skin
**Neuro
**Psych

Objective: (physical exam)
*Vital signs: (Pul, resp, BP, temp)
*General:
*HEENT:
*Neck:
*Cardiovascular:
*Resp:
*Abdomen 
*GU
*Extremities
*Skin
*Neuro
*Labs/tests: BGL, EKG would be the two big ones for EMS

Assessment: (complaint followed by working/differential diagnosis)

Altered mental status: Sepsis, [other differential diagnosis]

Plan: 

___ bore IV started on first attempt at ____ with fluids ran wide open. ___ fluid administered during transport.

Patient transported in semifowlers code 3 to ____. 

Sepsis alert called in route. [other treatments, etc]

[I would give each intervention on it's own line so that you can document the particulars of each intervention, such as number of tries, confirmation, site, etc as appropriate] 

Delta: 
[document patient's response to treatments and close with the transfer of care]


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## redbull (Jan 6, 2011)

Thank you! This was very helpful. B) I'm going to write up my experience in IFT so far later tonight. Hopefully it's helpful to inquiring minds.


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## Akulahawk (Jan 6, 2011)

SOAP notes are wonderful tools to learn for documentation. Most of the reports I've worked with do not provide enough narrative space to properly do a SOAP note. So on those, what I can't document somewhere else on the sheet, goes in the narrative. Give me a blank page and it'll likely look a LOT like JP's example above. I've seen BLS reports that devote about 70% to billing info, 20% to PMHx, Meds, Allergies, and 10% to narrative. Basically you get a small box to try to fit a narrative into it (and it won't fit...). I've seen reports that are usable for CCT --> BLS, but those were printed on legal sized sheets, not the standard letter size. And you almost could put a full SOAP note as above in the narrative space...


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## JPINFV (Jan 6, 2011)

Akula, one of the nice things that my first company did was provide narriative continuation sheets. Essentially it was a standard size sheet that was just lines outside of a header that contianed basic identifying information (name, DOB, date, and run number if I recall correctly).


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## Akulahawk (Jan 6, 2011)

JPINFV said:


> Akula, one of the nice things that my first company did was provide narriative continuation sheets. Essentially it was a standard size sheet that was just lines outside of a header that contianed basic identifying information (name, DOB, date, and run number if I recall correctly).


It's nice when they do that... this particular company didn't have them. Heck, their ALS reports looked like they'd been photocopied out of a textbook. :wacko:

Most companies that I worked for at least had (somewhere) available a continuation form. Finding them was usually a challenge.


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## JPINFV (Jan 6, 2011)

That's why I try to hoard things like that inside my clipboard.


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## Akulahawk (Jan 6, 2011)

JPINFV said:


> That's why I try to hoard things like that inside my clipboard.


I was a world class paperwork hoarder... when we had the paperwork available...B)


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