# BLS Narrative



## Smb (Oct 1, 2012)

so I'm a new EMT and I'm going through training with a new company I'm working for. Today I had a different trainer, we did a dialysis call and I wrote my narrative the way I was taught by the first trainer and the second told me to redo it his way. If I can get any tips from people on the site on how to improve on this, please let me know!

AOS to a 61 y.o. female Px. SMF @ dialysis. c/c ESRD s/p Hemo Tx. v/s WNL GCS 14. - CP - S.O.B. + ALOC - Ambulatory due to L BKA moved Px. to gurney w/ draw sheet. Transported Px. supine to SNF. - changes during transport. Px. care handed over to staff.

The only reason I ask is because I'm not sure which of the two trainers to go by since they have both been an EMT for relatively the same amount of time.


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## TransportJockey (Oct 1, 2012)

Honestly that report would not be acceptable anywhere i have ever worked. Once i get to a computer i'll type up a sample of my narrative


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## Smb (Oct 1, 2012)

thanks that would be great. I don't want to get into any bad habits just starting.


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## VFlutter (Oct 1, 2012)

I would just chart "Gomer go home"


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## Porta (Oct 1, 2012)

Try not to use abbreviations. There are others outside of EMS and the hospital that read your PCRs and they're not always going to know what the abbreviations mean.


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## TransportJockey (Oct 1, 2012)

Porta said:


> Try not to use abbreviations. There are others outside of EMS and the hospital that read your PCRs and they're not always going to know what the abbreviations mean.



As long as they are medicare approved abbreviations most places have no problems with them on reports. Billers will know what they are


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## Porta (Oct 1, 2012)

TransportJockey said:


> As long as they are medicare approved abbreviations most places have no problems with them on reports. Billers will know what they are



Hrm, good call. I always got chewed out for using them, but I worked for a small FD, and they weren't keen on us using a lot of abbreviations. Thanks for clarifying that.


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## Veneficus (Oct 1, 2012)

I prefer to use 0 instead of -. 

- is easily changed to +


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## usalsfyre (Oct 1, 2012)

http://www.trailblazerhealth.com/Education/CBTs/Default.aspx?DomainID=1

Look under non-accredited CBTs, and read the ambulance doccumentation presentation. It will save you trouble down the road.


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## Trashtruck (Oct 1, 2012)

So, this person was being transported from a dialysis center back to their nursing facility?

I'm assuming this was simply a ride home. A routine IFT, correct?

What's there to write that isn't already in your chart??? It's a ride back home. 

I've been out of IFT for a while, so I don't know what your company wants you to write in order to get paid for the transport. That's the name of the game and really what it boils down to. I guess the company needs you to explain why this pt needed an ambulance as opposed to a paratransit van.

I won't post what my narrative would be for this.


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## MSDeltaFlt (Oct 1, 2012)

Smb said:


> so I'm a new EMT and I'm going through training with a new company I'm working for. Today I had a different trainer, we did a dialysis call and I wrote my narrative the way I was taught by the first trainer and the second told me to redo it his way. If I can get any tips from people on the site on how to improve on this, please let me know!
> 
> AOS to a 61 y.o. female Px. SMF @ dialysis. c/c ESRD s/p Hemo Tx. v/s WNL GCS 14. - CP - S.O.B. + ALOC - Ambulatory due to L BKA moved Px. to gurney w/ draw sheet. Transported Px. supine to SNF. - changes during transport. Px. care handed over to staff.
> 
> The only reason I ask is because I'm not sure which of the two trainers to go by since they have both been an EMT for relatively the same amount of time.



Most companies bave standard operating procedures when it comes to charting.  Do what your company (not merely your trainer) says do.  As far as your abbreviations are concerned here's what I would suggest just for future references only.

Abbreviations are quick and easy.  However, quick and easy can sometimes be dangerous legally; especially when you chart those things out of habit and your patient is not presdnting with what you're charting.

If your GCS not 15 and not 3, it would be wise to chart WHERE the GCS is and I would chart that in your company's format.  Most use the E/V/M format  Her GCS was 14.  If she was confused with her eyes open, but would follow commands I would chart GCS = 14 @ 4/4/6.

I personally never use the phrase "V/S WNL".  I would actually get one set of VS at the very least.  Granted it is a NH take home after dialysis.  But who's normal?  Her normal?  Your normal?  Who's?

I don't use "-", "+", or "0" when referring to anything negative or positive.  I will write it out.  But that's just me.

Bare in mind I am in no way, shape, form, or fashion trying to belittle you whatsoever.  I just don't want you finding yourself in a situation where you might miss something leaving you "holding the bag".

Speaking from experience, missing something important involving your pt will make you feel like @#$&.

Hope this helps.


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## Aidey (Oct 1, 2012)

And remember

(-) Head and head (-) Are not the same thing.


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## Christopher (Oct 1, 2012)

Smb said:


> so I'm a new EMT and I'm going through training with a new company I'm working for. Today I had a different trainer, we did a dialysis call and I wrote my narrative the way I was taught by the first trainer and the second told me to redo it his way. If I can get any tips from people on the site on how to improve on this, please let me know!
> 
> AOS to a 61 y.o. female Px. SMF @ dialysis. c/c ESRD s/p Hemo Tx. v/s WNL GCS 14. - CP - S.O.B. + ALOC - Ambulatory due to L BKA moved Px. to gurney w/ draw sheet. Transported Px. supine to SNF. - changes during transport. Px. care handed over to staff.
> 
> The only reason I ask is because I'm not sure which of the two trainers to go by since they have both been an EMT for relatively the same amount of time.



You should follow some methodology, be it SOAP (Subjective, Objective, Assessment, Plan) or (D)CHARTE (Dispatch, Chief Complaint, History, Assessment, tReatments, Transport, Exceptions). Also important: how the patient got onto your stretcher or how you got them to your truck, how you moved them into their home, etc.

I also like to mention things like, "secured with seat belts, moved via stretcher to unit." Good to note proper seat belt use for patient.

And, "Pt moved via sheet drag to bed #2, safety rails engaged on bed."

If--err When--a patient you've returned falls out of bed a copy of your documentation signed at the receiving facility will note that you placed the safety rails up.

But as other folks have said...you need more meat and less abbreviations!


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## DrParasite (Oct 2, 2012)

TransportJockey said:


> Honestly that report would not be acceptable anywhere i have ever worked. Once i get to a computer i'll type up a sample of my narrative


umm why not?  It's an IFT, of a stable patient.  i don't see it as unacceptable, especially the rest of the chart is all check boxes.  maybe a little light on content, but better than some other people I have worked with.

to the OP, if you want to check out the "approved" medicare and medicaid abbreviations, check out this site: http://www.cms.gov/apps/acronyms/listall.asp?Letter=ALL

documentation is a very very very subjective thing.  what trainer 1 says is good trainer 2 will say is bad.  and what trainer 2 says is good trainer 1 might say is bad.  and when you ask trainer 3, he will say they are both wrong, and show you the "correct" way to do it.... despite the fact that trainer 1 and 2 will disagree.

The #1 documentation rule is make it documented enough that if you get called into court, you can defend your action, especially if you have little or no recollection of the call itself.  the #2 rule is to have enough documentation for the billing department to have the insurance pay the bill.

For me, I always start my narrative with "u/a, EMS found (patient in this position)."  from there I typically go into what the patient told me, as well as pertinent negatives, and then go into my assessment.  I then list my interventions, and culminating with "M+T to ER, tot RN in room # w/ report given."  I also never repeat anything listed in a check box in my narrative.  this includes vital signs and other check box worthy items (lung sounds, mental status, etc), unless there is a very specific reason that warrants duplication of documentation (which almost never happens).  every +, -, and = gets circled, as does every 1 letter abbreviation.

and my charts only get kicked back due to poor handwriting, never lack of content.  once we went to electronic charting, rarely were my charts were kicked back, unless I accidentally skipped a check box.

As a side note, I never write in my chart the patient was secured with seatbelts.  never have, never will.  every patient is secured with seatbelts, and only if they are not will that be noted in the documentation.  similarly, i don't document that the cot was secured in the ambulance, or that a blanket was given if requested, and I never write how many pairs of gloves I used (although this one probably causes the billing people headaches).  Certain things I do on EVERY call, and are common knowledge (sort of like where the mess hall is when you are in the marines).  Not only that, but just because I write it, doesn't make it accurate; the facility can just say I lied on the chart, and, in the case of the railings, they were never put up, despite what I put on the chart.


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## mycrofft (Oct 2, 2012)

TransportJockey said:


> As long as they are medicare approved abbreviations most places have no problems with them on reports. Billers will know what they are



Yes, but does the charting adequately document and convey that patient's infomation to document and continue care?

Reading such dense abbreviations all day long would give me a headache. In fact, as a case manager it used to. Learn from each preceptor and learn the company standard; and learn how to keep the essentials, lose the extraneous, and not let the format force you to fail to record and convey. That comes with time and repetition.


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## Anjel (Oct 2, 2012)

I could do a dialysis run in my sleep. 

ATF pt laying in dialysis chair. Pt had just finished their triweekly dialysis tx and is now returning home. Pt a&ox4 and in no apparent distress. Pt denies any complaints or discomfort. All vitals signs WNL as shown in PCR. Due to bilateral BKA pt is bed confined and cannot ambulate. Pt was lifted via sheet to the stretcher and secured. Pt transported in POC and monitored throughout transport without change. Upon arrival the their home pt lifted into bed and made comfortable. Care left with family. All without incident.


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## Achilles (Oct 2, 2012)

Since we're on the topic,

SOB or DIB?


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## Veneficus (Oct 2, 2012)

Achilles said:


> Since we're on the topic,
> 
> SOB or DIB?



SOB, it is one of the last double meaning acronyms we have left to describe patients.

http://www.messybeast.com/dragonqueen/medical-acronyms.htm


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