# Writing reports as paramedic



## wannabeHFD (Jun 20, 2013)

Recently I was dropped from my paramedic program after clinicals last month because my instructors felt my reports were not up to standard for paramedics. Though they did help me with some, I leave out a lot of information. At my job, we use computers to do our reports but since the ones for clinicals were handwritten I have difficulty writing everything they want to see. 

What's the difference in writing reports as a basic compared to a paramedic? I write everything I can think of, use all the tips they give us, but I my reports still suck. It's difficult to remember everything since there is much more involved especially major codes where I can practice my paramedic skills. I did fine with that at least and got many good calls, which did probably lead me to rush getting them all written before my shift was over. They have to be signed off by whoever we rode with and because of liability, we weren't supposed to stay after our assigned times. 

There must be some secret to writing great reports I'm just not getting...


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## firecoins (Jun 20, 2013)

You write what happaned. No leaving out info


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## Akulahawk (Jun 20, 2013)

I would say that there really isn't any secret to writing good reports. Think about a SOAP note and what's essentially needed info for a very basic report, or CHART note. These outline ways to write a report quickly and easily. After you've figured out which way they'd like you to document (or modify one of these to suit), you need to develop a boilerplate script that you simply have to fill in the blanks as you go. Another tip is to write this stuff as you go, if you can. This way you can finish the run, do the verbal report, and head out to write the reports you need to ASAP. 

SOAP is:
Subjective - anything anyone tells you that isn't otherwise verifiable
Objective - your physical findings. Write your Head to Toe here.
Assessment - knowing the above, what's your field diagnosis?
Plan - How do you intend to deal with the problem you've found

CHART is:
Chief Complaint - what someone tells you the problem is. Why they called you there.
History - PMHx, Meds, Events leading up to now.
Assessment - How you found the patient, scene description, ABCDE Primary & Your Head to Toe
R (Treatment on scene) - What was done on scene
Transport - what was done en-route. 

My program had us write run reports too... in addition to the regular patient care reports. I would write the regular report and as soon as I was done with the PCR, I'd immediately write the basics of the report they wanted me to write for them. 

Unfortunately, without seeing your reports and not knowing what they're looking for, I'm just taking a blind stab in the dark about what you need. 

What's different about writing ALS reports? Detail and depth. That's it. Nothing more. You should have better assessment skills, have seen things now that are helping you put things together, so get out of the mindset that you're BLS, because that will hold  you back. Having a computer to help you with your charting is nice, but you still have to know your pertinent positive and negative findings that lead you down the path to what you determined was wrong.


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## MMiz (Jun 20, 2013)

There is always a formula for writing, and it's the same with EMS.  Just as a formal paragraph requires a topic sentence, supporting details, and a clincher, you need to figure out what is expected in your report, write it down, and do it over and over again.

My company had us use the CHART method (as detailed above by Akulahawk).  Still, there was certain language that was expected of me, and I included it in every narrative.

Ours went something like:





> B100 dispatched priority 1 to 123 main street with A200 for a female complaining of chest pain.  ATF 38 y/o female sitting upright in chair.
> 
> _*(C)* Pt complains of _____________._
> _*(H) *Pt history and medications, learned by ________, listed below.  Additionally, _______________________
> ...



That worked at my old gig, but may be entirely inadequate in another service.  I'd learn what they expect to you and do it.

Good luck!


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## Arovetli (Jun 20, 2013)

Don't sweat it.
Just adapt to whatever your school or employer want you to say.

EMS in general has a wacky approach to charting.


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## wannabeHFD (Jun 20, 2013)

I know about soap and chart and I use them but there is always something that I overlooked 


firecoins said:


> You write what happaned. No leaving out info



It's not on purpose, it's just things I didn't think about putting in for one reason or another 




Arovetli said:


> Don't sweat it.
> Just adapt to whatever your school or employer want you to say.
> 
> EMS in general has a wacky approach to charting.


My reports at work have never been brought up to me so I guess I'm doing those right but even after trying every method and even having an instructor proof read them, I just can't get the hang of what they expect to see in reports. 

I hope to try getting my paramedic at some point but maybe I need more time as a basic before moving on. Frankly it terrifies me to be the paramedic in charge right now since the likelyhood of accidentally killing someone or getting sued is much higher, and I still struggle with all the material. Anytime one of them would quiz me, it's hard for me to answer even if I know it, but not well enough to give a good answer


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## Anjel (Jun 20, 2013)

wannabeHFD said:


> I know about soap and chart and I use them but there is always something that I overlooked
> 
> 
> It's not on purpose, it's just things I didn't think about putting in for one reason or another
> ...



Maybe this is for the best then. Sounds like you were dropped for more reasons than just report writing. Being a basic should definitely help with that, maybe take some A&P courses, and take the class again with more confidence.


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## abckidsmom (Jun 20, 2013)

When I'm writing the hpi section of the CHART method, I pause a second beforehand and the semi-template for that paragraph or two is like this:

Considering the differential diagnosis, I write about the onset and issues contributing to the onset, specific symptoms the patient is complaining of, including pertinent positives and negatives. Things the patient did to treat the issues, responses to those, and how they changed since the onset. 

Also remember the OPQRST line of questioning. That can be documented very efficiently in a sentence like "Pt complains of sudden onset of 10/10 crushing chest pain radiating to left arm and jaw while at rest today at 1500."

Another place I commonly see details lacking is in documentation of a full head to toe assessment, review of systems like: HEENT, neuro, chest/cardiovascular, abd, gi/gu, extremities and back.


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## Melclin (Jun 20, 2013)

I think its pretty hard to say whats wrong with your reports without seeing them and watching you practice. I'd seek more feedback from those who have assessed you and found your writing to be lacking. 

*My two cents on narratives:*
-Age, gender, relevant medical social hx, hx of the presenting problem up to the point ambulance was called. 
-O/A: A sentence describing the scene where neccessary eg O/A: "Pt laying wedged between toilet and sink having apparently fallen from sink top". 
-O/E: The subjective symptoms or complaints and pertinent negatives. Eg: "Pt c/o SOB, dizziness. Nil chest pain/discomfort, palpitations, nausea". Then the objective results of my exam and pertinent negatives, often broken down roughly (not too formal or strict about the categories) into systems or areas of assessment. Eg ABDO: Soft and pain free on palpation, nil masses, guarding, rigidity or distension. GI: Reports single vomit, of food only, nil haematemesis, melena, blood in stool, bowel movements as normal.  
-Provisional diagnosis and maybe a little justification unless its pretty obvious. "Proceeded as anaphylaxis" or "Dx: ?LRTI"
-Treatments and response. "Pain easily controlled with morphine, pt becomes nauseated approx 5 mins after morphine admin, single vomit of food only, nausea and vomiting resolves after metoclopramide, transport otherwise uneventful."

Usually no longer than a short paragraph, approx quarter of a page. The details (like drug dosages and times, vitals etc) are elsewhere on our sheets.


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## NomadicMedic (Jun 20, 2013)

For what it's worth, here's a typical chart that I write. We chart history, meds, vitals and such in a timeline...but this is a typical narrative.

Medic XXX and ambulance XX responded with lights and sirens (6-delta-4) to an 84-year-old male at a private residence complaining of left leg pain and swelling and increased shortness of breath. Patients wife related that the patient has had increased swelling in his left leg and has had difficulty in getting out of bed for the past four days. She relates his balance is off, he seems a bit lethargic and his breathing is more labored than usual. Patient relates that his left leg is causing him extreme pain whenever it is moved. Aside from the leg pain, the patient has no real complaint. The patient denied chest pain, difficulty in breathing, abdominal pain or discomfort, changes in movement or sensation aside from his left leg, headache, blurred vision or any other pain or discomfort. The patient relates he uses 2-4 lpm of oxygen at home PRN and has been using it more than usual. The patient's medical history and medication list is detailed below.

On my arrival I found an obese 85-year-old male lying supine in bed. The patient was extremely warm to the touch. He was conscious, alert and oriented 3/3 and was able to answer all questions appropriately. Examination revealed both of his lower extremities had +3 edema and discoloration. His wife related that the discoloration was normal but his left leg was significantly more swollen than usual. The patient was nonambulatory and was not able to stand and pivot or move from his bed without the assistance of four EMS providers. Further assessment is detailed below.

Prior to moving the patient he was transferred to 4 L per minute on EMS oxygen, with nasal prongs to measure end tidal CO2. It was noted the patient had a respiratory rate of 24 with an unobstructed end tidal wave form of 34. The patient had a ventricular demand pacer at a rate of approximately 80. Initial blood pressure 128/62. A stick on temporal temperature strip read approximately 100°. The patient was moved from the residence via a stair chair and then to the stretcher. IV access was obtained in the left AC with a 20 gauge catheter. A serum lactate was obtained and read 3.3 mmol/L. Phlebotomy samples were drawn. Patient received approximately 500 ml of normal saline while en route. 12 lead EKG was captured, showing a paced rhythm. Medical control with Hospital was established via radio, advised ETA and status of patient as priority three.

On arrival at Hospital the patient was moved to bed 19 and a verbal report, blood samples and the patient's medication list were all given to the RN at bedside


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## mike1390 (Jun 20, 2013)

DEmedic said:


> For what it's worth, here's a typical chart that I write. We chart history, meds, vitals and such in a timeline...but this is a typical narrative.
> 
> Medic XXX and ambulance XX responded with lights and sirens (6-delta-4) to an 84-year-old male at a private residence complaining of left leg pain and swelling and increased shortness of breath. Patients wife related that the patient has had increased swelling in his left leg and has had difficulty in getting out of bed for the past four days. She relates his balance is off, he seems a bit lethargic and his breathing is more labored than usual. Patient relates that his left leg is causing him extreme pain whenever it is moved. Aside from the leg pain, the patient has no real complaint. The patient denied chest pain, difficulty in breathing, abdominal pain or discomfort, changes in movement or sensation aside from his left leg, headache, blurred vision or any other pain or discomfort. The patient relates he uses 2-4 lpm of oxygen at home PRN and has been using it more than usual. The patient's medical history and medication list is detailed below.
> 
> ...



This... I use a tad more abbreviations, but as long as all the info gets across this would cover it.


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## Arovetli (Jun 20, 2013)

Thats well done sir.


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## Akulahawk (Jun 20, 2013)

DEmedic said:


> For what it's worth, here's a typical chart that I write. We chart history, meds, vitals and such in a timeline...but this is a typical narrative.
> 
> Medic XXX and ambulance XX responded with lights and sirens (6-delta-4) to an 84-year-old male at a private residence complaining of left leg pain and swelling and increased shortness of breath. Patients wife related that the patient has had increased swelling in his left leg and has had difficulty in getting out of bed for the past four days. She relates his balance is off, he seems a bit lethargic and his breathing is more labored than usual. Patient relates that his left leg is causing him extreme pain whenever it is moved. Aside from the leg pain, the patient denies any other complaints. The patient denied chest pain, difficulty in breathing, abdominal pain or discomfort, changes in movement or sensation aside from his left leg, headache, blurred vision or any other pain or discomfort. The patient relates he uses 2-4 lpm of oxygen at home PRN and has been using it more than usual. The patient's medical history and medication list is detailed below.
> 
> ...


As others have said, that's pretty good. I might add or change a couple things to the above, in red... for clarity. To the OP, you want to be able to show what findings led you to the field diagnosis. Why was this probably not DVT and more likely a cellulitis with sepsis...

Writing down _why_ you chose that over something else meant that you considered positive and negative findings and also you have documented that. You're more likely to have a better report by simply doing that. Later, when you're at home, you could look up the problem and learn why that problem occurs. The more often you do that, you're more likely to pick up on those things again in the future and document those findings. If you have time before you can restart the program, I strongly recommend you take an A&P course, at the minimum.


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## TheLocalMedic (Jun 21, 2013)

I use the VOMIT method.  

I give a quick run down on how I found them (helps me remember what the heck the call was even about later) and what they complained of.  Throw in pertinent positives and negatives.  

V    Vitals

O  Oxygen

M   Monitor

I   IV

T   Treatment/Transport


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## Akulahawk (Jun 21, 2013)

Something we all forgot to add/expand upon is that the amount we write and style we use is often directly related to the amount of space available (and format) of the patient care report.


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## Handsome Robb (Jun 21, 2013)

Akulahawk said:


> Something we all forgot to add/expand upon is that the amount we write and style we use is often directly related to the amount of space available (and format) of the patient care report.



True.

The majority of writing a chart for me is selecting drop-down menus and clicking bubbles with the occasional quick note in a comment section.

At the end I generate a narrative that pulls everything I selected into the narrative section and I have to do a quick subjective section, response to treatment/changes en route section, sign it, Bluetooth an ECG and boom goes the dynamite.

I guess for the point of this thread it is formatted in a SOAP format.


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## Wes (Jun 25, 2013)

Obviously, you have to do whatever your educational program or employer want, but here's my $0.03 (adjusted for inflation, ya know).

With electronic charting becoming more and more prevalent and capturing the majority of your interventions and assesment findings, I find that a straight narrative works quite well.  In other words, start at the dispatch and tell a chronological story.  Don't worry about SOAP/CHART/etc.   Tell a chronological story and you'll capture the details.   This is how the cops write their reports.   They write their reports like every report they write will be going to court -- because many of their reports do.

As Joe Friday used to say, "Just the facts, ma'am."


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## socalmedic (Jun 28, 2013)

I use JPVINE's format now that I am on EPCR, formerly a very short 4 sentence that fit on the one page carbon copy LA county PCR. many of my partners make comments about how long my narratives are but once you have the format memorized it is very fast. my narratives are about one page of 12pt times new roman.

if you want a great article on how to write a long chart check out JPs blog below and read the whole series on his Pre-SOAPeD narrative. is basically SOAP with the pre-arrival (dispatch info) and Delta (Changes) on the end.

http://emtmedicalstudent.wordpress.com/2011/01/20/ems-documentation-introducing-pre-soaped/


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## Zohie Allgood (Sep 4, 2014)

COOL EVERYBODY HAS DONE A GOOD JOB ON THIS


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## Jason (Sep 5, 2014)

At our squad and the whole county, we use the Field Bridge program for information input and report charting.  I was taught to also use the CHART method.  Conveniently under our Narrative tab, the Set Narrative sets up our narrative in CHART format automatically and auto-populates info into each section.  
However, with or without computer charting programs - it's so important to know what to report and how.  
I don't know how long you've been an EMT Basic, but what is needed to report as a paramedic is more in-depth.  
Best of luck to you.


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## joshrunkle35 (Sep 7, 2014)

Depth of your assessment will come with being really good at your paramedic skills, especially the medical portion, and then the documenting portion just follows the way you think.

Let's say you get called to an Altered Mental Status patient. So, right off the bat, you should know, it could be a blood sugar issue, a psychological issue, a drugs or alcohol issue, a UTI in the elderly, a possible head injury, a possible stroke or some other chemical imbalance/toxin. The doctor or nurse reading your report/chart are going to be thinking the same things, and since you may be first on scene, you are the first real medical person to give an initial impression and assessment. This may form a crucial baseline or history for the future of this patient. The goal of your chart/report is not to say odd things that stand out, it is to show what has been checked and evaluated at that time. 

For example, if your patient isn't stumbling as they walk, you might not think right now to note it. But let's say that an hour later they start stumbling. The doctor won't know whether they were stumbling and you forgot to note it, or they were stumbling and you didn't notice it, or if the patient is getting worse because they weren't stumbling earlier, but now they are. But, if a doctor can read, "No ataxia or unusual gait or awkward movements noted at this time" at 1400 and it's now 1600 and the patient now has ataxia, well, that gives the doctor a major clue that this patient may be getting worse. Pertinent negatives are just as important as pertinent positives. 

In my example of an altered mental status, you should do every evaluation for all of those possibilities, until you have significant information, like a patient tells you that they have diabetes, they left their insulin pump at home and your glucometer reads "HI", or they specifically tell you that they just took recreational drugs, etc...


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## Ewok Jerky (Sep 8, 2014)

If it is that bad you should be using a template.  Get one from school, your preceptor or on line. Don't cut corners, do a full HPI (history of present illness) and a full H&P (history and physical) on every patient until you hone your spidey senses.  Ask and document a review/physical for every system every time (general impression, skin, respiratory, cardiac, GI, musculoskeletal, neuro, behavioral, endocrine, and if appropriate ENT, hematologic, genitourinary)


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## Ewok Jerky (Sep 8, 2014)

Also SOAP is a very easy format once you understand it for your narrative.

SUBJECTIVE: Everything you hear or are told including what family tells you, what the patient tells you, and what bystanders tell you.  This includes answers to your OBQRST and other subjective questions .  Think of this as everything that could be put in quotations.

OBJECTIVE: Facts. Things you see, things you find, things you observe such as physical exam, information from medical records, labs, Etc.  Response to treatment can go here in EMS setting.

ASSESSMENT: what is your working diagnosis or differential?

PLAN: what are you going to do (treatment, transport decision).


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## Bullets (Sep 8, 2014)

I don't chart things that don't happen. Only what happened, only what the patient tells me or I can see or assess. I don't understand why period put things like negative chest pain, sob, Neuro defects ect. As far as I'm concerned, a blank chart with just demographics is a perfectly healthy normal human, I then document the areas in which the patient stays from normal. But that's how our system has progressed. We're changing charting systems so I'm sure that will change


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## Ewok Jerky (Sep 8, 2014)

Bullets said:


> I don't chart things that don't happen. Only what happened, only what the patient tells me or I can see or assess. I don't understand why period put things like negative chest pain, sob, Neuro defects ect. As far as I'm concerned, a blank chart with just demographics is a perfectly healthy normal human




You don't document pertinent negatives?  So your patient complaining of SOB could be COPD, asthma, MI, PE, anxiety, PNA etc...
Documenting pertinent negatives is crucial to crossing things off your differential. 

A blank chart to me is useless because I don't know what you asked about or any of your physical findings.  It doesn't indicate a normal human it indicates a lazy provider.


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## Bullets (Sep 9, 2014)

beano said:


> You don't document pertinent negatives?  So your patient complaining of SOB could be COPD, asthma, MI, PE, anxiety, PNA etc...
> Documenting pertinent negatives is crucial to crossing things off your differential.
> 
> A blank chart to me is useless because I don't know what you asked about or any of your physical findings.  It doesn't indicate a normal human it indicates a lazy provider.


Physical findings would be things i asses, so they would be documented. Which I said i already do. Which of those conditions you mentioned dont have other clinical signs we can measure or note?

Why would you say its not copd, asthma, mi, just say what it is?


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## Handsome Robb (Sep 9, 2014)

Bullets said:


> Physical findings would be things i asses, so they would be documented. Which I said i already do. Which of those conditions you mentioned dont have other clinical signs we can measure or note?
> 
> Why would you say its not copd, asthma, mi, just say what it is?


Because, especially at the BLS level, you cannot say that. As a paramedic if my monitor shows a STEMI I'm going to call it that but I'm still going to list pertinent negatives that I asked about. You need to be asking these questions because people don't always know what to offer up as information unless asked.

EMS personnel do diagnose, I'm not saying we don't form a working diagnosis but if your charts are just saying, "The patient is experiencing a CHF exacerbation" then your assessment findings you're not performing a good enough subjective assessment. Yea subjective isn't always accurate but it needs to be documented. Now if the patient has a single complaint and adamantly denies any other symptoms then that is exactly what I document. "The patient complains of retrosternal chest "pressure" radiating into his left jaw and shoulder. The patient adamantly denies any other associated complaints".

PCRs are a legal document and need to be thorough, otherwise you're (not you specifically, generalized 'you') are going to look real dumb when your chart is blown up on a huge screen in front of a court room and you didn't document well enough.


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## Ewok Jerky (Sep 9, 2014)

Bullets said:


> Physical findings would be things i asses, so they would be documented. Which I said i already do.



Part of "clinical signs we can measure or note" includes asking and documenting about associated conditions to make sure we are covering our bases.  When I have a 75 y/o F who appears dehydrated and just started HTCZ and feels dizzy, I don't just write "orthostatic hypotension", I also ask about chest pain, nausea, SOB etc to rule out MI.  When I have an obese 55 y/o M with chest pain after golfing, I ask about hx of GERD and diet/last meal type questions to consider other sources of chest pain/discomfort.  I am not knocking your clinical skills but your documentation and verbal reports will rock if you include these pertitent negatives.

I also forgot to mention the importance of pertinent negatives for reassessment and trending a patients condition.  The obvious examples are evolving cardiovascular events like stroke and MI, but you can also imagine response to treatment or more likely decompensation despite treatment.


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