# HELP...Run Report Narratives



## EMT_TIFFANY

Need advice on writing narratives for run reports. We didn't practice it enough in basic and I don't run anywhere. I'm hopelessly lost at this time. Can anyone direct me in the path of how to write an organized and complete narrative. Any help would be GREAT  :wacko:


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## comet2003

Tell a story about what happend on the call. You always want to make sure that if someone who was not there could follow your call and know what you are doing.


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## Anto

ICHART

Incident
Chief Complaint
History
Assessment
Rx
Transport


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## MRE

I always start my reports, "Called for XX year old pt with XX complaint"  Arrived on scene to find: (initial condition of pt, any pertinent info on location (lying on floor, sitting in chair, hanging off roof, etc.) then initial vitals, treatment on scene, method of transfer to ambulance, additional findings during assessment, condition and treatment during transport and anything else that might be helpful to know or explain an oddity in the fill in boxes above on the PCR.


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## resq330

W1IM said:


> I always start my reports, "Called for XX year old pt with XX complaint"  Arrived on scene to find: (initial condition of pt, any pertinent info on location (lying on floor, sitting in chair, hanging off roof, etc.) then initial vitals, treatment on scene, method of transfer to ambulance, additional findings during assessment, condition and treatment during transport and anything else that might be helpful to know or explain an oddity in the fill in boxes above on the PCR.





+1   


And *Document...Document...Document...*.  If you don't document it then it didn't happen.  Just to CYA if it ever gets pulled into court.


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## medicdan

Do a simple search on this site for some past discussions of PCR narratives. For a stat, see:
http://www.emtlife.com/showthread.php?t=14880
http://www.emtlife.com/showthread.php?t=13018
http://www.emtlife.com/showthread.php?t=13425


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## Dominion

My run reports resemble the following:

"Pt found sitting upright c/o weakness.  Patient states "I've just felt sick the last few days and have gotten weaker.  Today I couldn't get out of bed" also states "I can't keep anything down".  Intial vital signs obtained as listed above, - soa, - CP, +N/V x3 days.  - loc, a/ox4.  Placed on O2 @ 4lpm via NC. Patient moved to ambulance with assistance to stretcher, -> C-X to Hospital.  Enroute: V/S monitored as attached (Note I attach a record of my vitals), O2 maintained @ 4lpm, aquired chemstick, physical exam performed with initial findings as above (Note Initial findings are listed above).  Upon Arrival to *hospital* - Changes in condition.  Patient triaged, xx minutes, care transferred to ER Nursing staff.  END"

Generally.  IT changes of course but that's been a common narrative as late.  I usually write 2 page reports as we have not gone to ePCR yet.


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## MrBrown

Something like this works well for me: 

-Impression
-Assessment including pertinant negatives
-Treatment and response 

For example this is roughly a job I went to on Thursday

"Located 65yof sitting in lounge chair in company of daughter.  Pt awake and alert to crew presence w/o signs of obvious injury or illness.  Daughter states patient seen by AOs previous evening (PRF No. XXX) cc N/V but not transported.  Pt states she felt unwell since Tuesday now feels dehydrated w/ increased urination, hx IDDM for which she takes insulin but has taken since 7am Tuesday and latest BGL 10am this morning read high.  BGL obtained at 11.7.  18ga. IV L forearm > 1L NS TKO."

Note that we record vital signs seperately in another part of our form.


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## Dominion

My suggestion is to not be lazy with your run report.  Right down what you find and what you did.  If you did not do it or do not write it down, IT DID NOT HAPPEN!  If you are taken to court and you say "oh well I did that, I just forgot to write it down" you will get eaten alive.  

I usually don't record my exam findings IN the narrative just because we have a page for 'initial physical exam' which lists all the normal things you're looking for.  ABC's, extremeties, chest, abdomen, etc.  I will write exam findings in the run report if I repeat them and they change,or the patients condition changes: for example something like below.

"Pt found lying supine c/o H/A.  Pt states "this is the worst headache I've ever had", reports no Hx of migrages, stroke/tia, seizures.  Pt pale, reports H/A @ 10/10 pain and along L temporal region, does not migrate.  Pt states H/A since approx 11am today (11/17), has taken 1gm OTC Tylenol s relief.  Initial vitals taken as recorded above, O2 placed on pt @ 4lpm via NC, moved to ambulance via stretcher.  -> C-1 *hospital*.  Enroute V/S monitored as attached (attach to run), O2 maintained @ 4lpm NC, chemstick and physical exam c findings above.  Approx 5 minutes from *hospital* pt states "I don't feel right", facial droop visible.  stroke scale performed with pronounced weakness on R side, + Facial droop, + Arm Drift, + Motor Function Loss, + Speech Impairment.  -> C-3 (time), *hospital* called, report given, request for stroke team approved.  Arrived to *hospital* c no further changes, bypass triage to stroke team.  Care transferred to stroke team s incident."

The above is an example of a stroke I had recently with some changes and some of it I don't remember so I made parts up


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## JPINFV

Dominion said:


> My suggestion is to not be lazy with your run report.  Right down what you find and what you did.  If you did not do it or do not write it down, IT DID NOT HAPPEN!  If you are taken to court and you say "oh well I did that, I just forgot to write it down" you will get eaten alive.



To add on to this, if you didn't do something for a reason (i.e. short transport time or other factors) document the reason.


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## Aidey

I personally am a fan of the CHART method of documentation. For one I find that it is easier than SOAP, and also because the majority of reports done by doctors I've read roughly follow CHART. I think providing a narrative to the hospital in a format the MDs and RNs are familiar with makes it easier for everyone.

CHART is CC, HX, Assessment, Rendered care, and Transport. 

Here is an example of a CHART narrative. In real life the computer program we use has a seperate place for past history, meds, allergies, interventions and vitals so none of those make it into the narrative unless they are pertinent to the situation. For example, the before and after blood glucose numbers in a hypoglycemic patient, or before and after BPs in a Pt given a fluid bolus. 

CC: R wrist pain

HX: The patient is a 17 year old male being transported from a skate part this evening. History is obtained from the patient and bystanders on scene. Pt state that while executing a trick on his skateboard he lost his balance and fell forward onto the concrete surgace with his arms outstretched. When he landed on his outstreched hands he felt and heard a "snap" in his R wrist, and he also had an acute onset of pain in the extremity. A bystander obtained ice and placed it on the pts wrist while they waited for EMS to arrive on scene.

The pt states the pain is a 6/10. Moving or touching the wrist exacerbates it, and holding it still reduces the pain. _(Note, this isn't a complete OPQRST because quality, radiation, and time aren't really relevant in this situation).  _

The pt was wearing a helmet, and denies hitting his head or LOC. He was not wear wrist guards. His last oral intake was at 1200 today. He denies drinking alcohol or abusing medications or illegal drugs. 

The pt has a past medical history of ADD, for which he takes Adderall. He has NKDA.  

Assessment:
General: Pt contacted lying on the ground. Pt is stable.
Neuro: GCS 15. No LOC
HEENT: Airway open. Eyes PERLA. No cyanosis noted around the mouth. 
Neck/Back: Trachea midline. Pt denies neck or back pain. No DCAP-BTLS, TIC or step off noted on palpation of the spine.
Chest: Equal and bilateral chest rise and fall with inspiration and expiration. Lung sounds clear and equal in all fields.
Abd: SNT. 
Extremities: CSM intact x4. The pts R wrist has a deformity on the lateral side when compared to his L wrist. There is swelling present and bruising along the lateral side. Cap refill in R hand is less than 3 seconds. Pt can move his fingers, but can not move his wrist without pain. Pt denies numbness or tingling in his fingers. 

R: Assessment. Vital signs. Pts R wrist placed in a cardboard splint and splinted in position of comfort. Cold therapy applied to wrist. CSM rechecked every 10 minutes during transport. 

T: Pt contacted his mother via cell phone prior to EMS arrival. She instructed the pt to go to Children's Hospital and she would meet him there. Pt ambulated to gurney. Seat belts applied to pt and gurney was moved to the ambulance. Pt was transported to Children's Hospital at parent's request and transferred to room 10. Care was turned over to the nursing staff there.


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## Aidey

JPINFV said:


> To add on to this, if you didn't do something for a reason (i.e. short transport time or other factors) document the reason.



This is a big one for me, it's easy to remember why you did something, but it isn't easy to remember why you didn't do it. In my narratives I stick this under the treatment section. Say I have a patient with a port, I would write "Pt reports that he has a port in his right upper chest. Since pts vital signs were stable, peripheral IV access was deferred in favor of the pts port being accessed at the ER."


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## Dominion

As a basic, you should not really have to document why you didn't do something ,unless it's related to a short time period or there are specific circumstances.  For the most part you should be able to perform all of your skills on every patient.  Generally the only time I don't will be examples like 

"Unable to obtain V/S, patient refuses physical assessment"

"Unable to obtain additional V/S due to short transport and multiple patients." (We transport two patients on one truck if injuries are not too severe...this has bitten me in the butt before though)

"Unable to obtain BGL due to equipment failure"

These are some examples I can think off the top of me head.  Generally though 95% of your patients you can do everything to the best of your ability.  

What I found to help me was to think up scenarios, try to get all forms in.  Do some mundane calls, transports, traumas, etc.  If you can find an EMT or Medic who precepts new students (or your teacher if you're still in class) see if they will look at your mock run forms and evaluate them.  Most states have a 'state default' form you can download from your states EMS website.

Some example scenarios to write up:

Trauma (can be anything from a minor fender bender to major traumas)
Elderly person who fell 1 week ago, feels fine but would still like to get checked out just in case.
Middle aged person with abdominal pain
BLS full arrest
Seizures 
etc

Do 1-2 a day, and you should start to fall into a rhythm.  If you work try to make sure you do a complete set of paperwork before clearing the hospital.  Your partner will need to be patient while you learn.


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## JPINFV

Dominion said:


> As a basic, you should not really have to document why you didn't do something ,unless it's related to a short time period or there are specific circumstances.



...and this is exactly why I mentioned it. There's essentially a rule 34 for EMS scenarios and actual runs. If you can think of a scenario, it's happened.


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## SanDiegoEmt7

JPINFV said:


> ...and this is exactly why I mentioned it. There's essentially a rule 34 for EMS scenarios and actual runs. If you can think of a scenario, it's happened.



That is awesome


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## EMT_TIFFANY

Dominion said:


> As a basic, you should not really have to document why you didn't do something ,unless it's related to a short time period or there are specific circumstances.  For the most part you should be able to perform all of your skills on every patient.
> 
> I'm currently a Paramedic Student, I haven't used this skill since my basic, that is why I needed some refreshment. TO ALL WHO HAVE REPLIED... thank you so so much for all your help. As I began writing them it started to come back to me with your help. I think I still need a lot of practice though. Thanks so much!!!:


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## Michael Sykes

As stated in a previous response, I am a retired volunteer firefighter/EMS First Responder. Our FD uses a two-page medical form similar to a NFIRS fire reporting form. As a first responder, trying to read one of the reports filled out by some of our EMT's and Paramedics is a problem when it comes to the abbreviations. If, for some reason, I were to be called into court to testify, and this report was the only ammo I had, I could be screwed. Just remember, plain English beats abbreviations anytime; it may not be a "professional" EMS person trying to decipher a report.

As an example, one of the examples posted used an example of starting an IV. I followed everything, including left forearm, one liter normal saline, but what the heck does TKO mean? Remember, we're a volunteer fire dept. (non-transport) that backs up Rural/Metro Ambulance, whose employees make up many of our firefighters. We are only certified to First Responder level, so we're strictly non-invasive.


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## Aidey

Theoretically the only person testifying about the contents of a report in court should be the person who wrote it. The only way I can see someone else testifying about them is if the contents are being challenged. I'm not sure why you would be testifying about what happened in a report someone else wrote.

That being said, not going over the top with abbreviations is good. There are some that are standard across the board though, and you might want to do training on them so your fire fighters are familiar with them.


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## Dominion

Michael Sykes said:


> As an example, one of the examples posted used an example of starting an IV. I followed everything, including left forearm, one liter normal saline, but what the heck does TKO mean? Remember, we're a volunteer fire dept. (non-transport) that backs up Rural/Metro Ambulance, whose employees make up many of our firefighters. We are only certified to First Responder level, so we're strictly non-invasive.



Generally if you WANT to use abbreviations (which I do when I'm trying to be short and sweet) you want to use RECOGNIZED medical abbreviations.  TKO is a recognized medical abbreviation that almost every person working in the ED should recognize or you may see c with a line over it which means 'with' or an s with a line over it which means without.

sz = seizure
tx = treatment
q = every (for example "Give Nitro q 5 minutes")
A/O x 4 (Alert and oriented times whatever number)

Those are a few examples of accepted abbreviations in the medical field.  You don't want to write a report that is 90% abbreviations.


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## Aidey

Funny side note...my grandmother was a nurse for 30 years from the 40s-50s to the 80s I think. I while back I inherited something from her, there was a note with it that had been written in 1958. In the note she used the /c as 'with'. I didn't realize that abbreviation had been around for that long.


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## Lvillemedic

*Pertinent Negatives..Don't forget these!!!!*

Something I always add is the pertinent negatives..i.e. Pt c/c of rapid heart rate, but pulse normal and NSR on monitor, or showing STEMI with out physical signs or symptoms also known as a silent MI..

As for abbreviations: Do not use ETOH unless you can fully state what ETOH is..besides alcohol intoxication... an attorney will eat you alive in court. I alway use "smells of alcoholic beverage" because alcohol by it's self has no smell or color....I also like the little triangle that stands for changes and is well known in the hospitals......Atleast around here....


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## JPINFV

To be fair, it should be EtOH. Actually, thinking about it now, I'm tempted to put CH3CH2OH.  (also, purely technically speaking, alcohol is bad to use. Methonal poisoning is a type of alcohol poisoning)


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## akflightmedic

Lvillemedic said:


> Something I always add is the pertinent negatives..i.e. Pt c/c of rapid heart rate, but pulse normal and NSR on monitor, or showing STEMI with out physical signs or symptoms also known as a silent MI..
> 
> As for abbreviations: Do not use ETOH unless you can fully state what ETOH is..besides alcohol intoxication... an attorney will eat you alive in court. I alway use "smells of alcoholic beverage" because alcohol by it's self has no smell or color....I also like the little triangle that stands for changes and is well known in the hospitals......Atleast around here....



Exhibits or displays behavior consistent with substance abuse...then mention slurred speech, staggering, quotes, smells, etc. Not saying he is or isn't, but describing behavior consistent with it all. Just be sure he doesnt have low BGL or a head injury.


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## MRE

akflightmedic said:


> Just be sure he doesnt have low BGL or a head injury.



I have always found it interesting, how several completely unrelated ailments can present as intoxication, and have tried to educate people about them.  We had a guy crash his pickup in the parking lot of my payin' job, and many people believed it was due to ETOH, just because of the nature of the incident.  Turns out that the guy had some kind of allergic reaction to a shot he got earlier that morning, causing him to enter an altered mental state and finally go unconscious with his foot on the gas.


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## ecampvet

BART-Body Assuming Room Temperature
DWPA-Death With Paramedic assistance
ABC-Ambulate Before Carry

I use Dispatch-CC-HX-***-RX/TX-EXTRA

We use the all-too-horrible Zoll E-PCR so everything is already on the form so only a brief overview is really necessary.

GOMER-Get Out Of My Emergency Room


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## ecampvet

WNL= We Never Looked


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## Jim37F

We use a simple chronological narrative of what we saw and did.

"(Age)(M/F) found (position found) A&Ox_ (AVPU if not A&O) c/o (complaining of)____ 2° to (MOI). Pertinent positives. Pertinent negatives. Any additional injuries/acute medical issues found (e.g. c/c SOB w/ no CP but found an acute arrhythmia on the monitor). Treatment(s) rendered. Transported to (Hospital) for (eval and treatment/definitive care/specialty center (Stroke, STEMI, Trauma, etc.)"

Example: "85 y/o M Pt found sitting upright in chair inside store. Patient A&Ox3/4 (- event) with repetitive questioning. Pt c/c left arm pain and neck and back pain 2° to mechanical slip and fall backwards off approx. 4 steps with loss of consciousness and unable to remember event and seems dazed and confused. 1" hematoma found on back of patients head. L forearm bruised and tender. No other injuries found. Pts placed in full SMR and L arm splinted. Pt transported C3 to (Trauma Center). Pt monitored enroute with -changes."


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## NomadicMedic

Here's one of mine:

Med 1 responded priority to a 57-year-old female at a private residence with a complaint of abdominal pain. Patient related that about 40 minutes prior she began vomiting, with a sudden onset of severe abdominal pain. She related there was no blood in her emesis. Her last oral intake was approximately six hours before, consisting of a sandwich, which was a normal meal for her. She related that she had both her appendix and her gallbladder and has never experienced gastro distress of this type before. She also related that her last bowel movement was approximately three days ago. She has had a hysterectomy. Aside from the abd pain, she had no other complaints. She related a history of hypertension and back and knee pain, secondary to arthritis, for which she was under treatment. Her medications are listed above, and she has no drug allergies, but is allergic to latex.

On EMS arrival, the patient was found on her hands and knees, next to her sofa, complaining of 10 out of 10 abdominal pain. Patient was warm and dry, breathing regularly and had a normal pulse rate. No immediate life threats were noted during the initial exam.

The patient was assisted in standing and taking several steps to the ambulance stretcher, which was placed at the door to the house. The patient was assisted to the stretcher and secured with all straps and then moved to the ambulance for additional treatment and none merge t transport to Xxx Hospital.

In the ambulance the patient was placed on the cardiac monitor and found to be in sinus rhythm at a rate of 70. There was no ectopy noted. Patient's BP 126/80, blood sugar measured at 118. The patient was placed on 2 L of oxygen via nasal cannula and SPO2 was 100%. IV access was obtained in the left AC with a 20 gauge catheter and secured with 10 mL of normal saline and a lock. Patient received 4 mg of Zofran slow IV push and the IV was flushed with 10 mL of NS. A telephone report to xxxx hospital was made, advising the patient's condition and ETA. Patient was monitored for changes during transport, and the patient related relief from her nausea. Transport was without incident.

On arrival, the patient was moved to treatment room one, assisted to the bed and all rails were raised.  A verbal report was given to the RN at bedside, and the patient's pocketbook was left in possession of the patient. Signatures from the patient and the RN were obtained, a copy of the privacy policy was left with the patient and med 1 returned to service


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## Jim37F

^ That's awesomely detailed, only problem is that it's about 5 times bigger than the amount of space we have for a narrative on our run forms.


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## NomadicMedic

Wow. That sucks. 

I've said it before, and I'll say it again, your outlook on narratives will change about 5 minutes into a deposition.


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## cruiseforever

Jim37F said:


> ^ That's awesomely detailed, only problem is that it's about 5 times bigger than the amount of space we have for a narrative on our run forms.


 
Is it EPCR or paper PCR?  If it's paper I would start a second form.  I find the EPCR that we use will record as much detail as I care to write.


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## Angel

uh...i use the "CHART" method and it seems to work just fine. if its not pertinent to the issue at hand its not likely to be included (though in some cases if it helps with the back story it will be)
i like to keep it short, sweet and to the point.
you have good examples so unless you really want one from me...ill let you stew on that.

it will take time to develop your own style, but i say pick one from a partner or supervisor and stick to that format until you're comfortable to venture away on your own. But keep in mind, as others have stated, it could end up in court so be as specific as possible without being redundant or providing irrelevant information. (which only you would know if it is relevant or not)

ETA: he shouldnt need a second form if hes being precise and using short hand. (my county and most have an approved abbreviations list) The only time I ever used a continuation is when I was new.


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## NomadicMedic

...or use the charting standard that you department or company wants. One you find a system you like, stick with it.


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## Angel

If that was the case I don't think this thread would've even been started. Most, in fact none of the places I've worked care what method you use as long as certain information (ie billable) is included. I use different formats for 911 vs IFT because there really isn't much done for transfers besides monitoring.


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## NomadicMedic

Funny, every agency I've worked for, both private and government, 911 and IFT, all had charting standards. 

I'm used to twisting my standard narrative around to make it fit the standards.


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## Brandon O

DEmedic said:


> Here's one of mine:



This is beautiful. If you want any input, though, I would suggest you can omit all the "she related" and similar fillers ("pt states," etc). It can be presumed the source of information for a patient history is the patient unless otherwise noted.


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## gotbeerz001

Jim37F said:


> ^ That's awesomely detailed, only problem is that it's about 5 times bigger than the amount of space we have for a narrative on our run forms.


I'm sure there is a Form B with more room for a narrative.


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## Angel

Yea, the standard of being billable, that's what I said.


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## Jim37F

Well a unique issue for my current departments ePCR that I don't think any of you guys have to deal with is that it pretty much HAS to be written by the Paramedic on their iPad, and then transferred to our unit's iPad before we can transport BLS. In a decision that apparently made sense to the chief officers who decided on it,w hen they do so, the software on our BLS iPad locks out many features, including the narrative. I literally cannot go in and edit the narrative. IF I catch the engine medics before they leave I can push the form back to them and they can change/edit and then push back to me, but if they're already gone...well it is their signature on the form....Not my favorite answer by any means but sadly thats the way it is here.

But for the old paper PCR's we keep as backups, along with those of both the private companies I used to work for, the forms were of the ilk that you had to press hard while writing to transfer to three different pieces of paper (one stayed with the company for our records, one stayed with the patient for their medical records, one went to the County EMS office and so on) so if I REALLY wanted/needed to write a second page, I'd have to start a whole second PCR and include all the other bits of header data (Pt info, pickup and dropoff locations, dispatch/enroute/onscene/transport/transport complete times, vitals, EVERYTHING) would have to be replicated in order to do a narrative continuation on a second page, now where the narrative box will literally only fit one of those 5 paragraphs DE wrote....well you can see redoing 6-8 PCRs 5 times each over the course of a single shift would simply become a huge hassle that would have gotten me hauled into the supervisors office asking why I'm wasting so much paper to write out so much redundant detail already covered in other places on the PCR.

It was simply not realistic on routine PCRs to write out such a long and detailed narrative. The only official Page 2 we have is specifically for advanced ALS procedures like intubations and cardiac arrest resuscitation.

Since I'm not at work I don't have access to a blank copy of my current PCR software, but it's one of those programs designed to look just like a single page paper PCR that you then tap on a section and it brings up the appropriate boxes to edit info, and once your done is designed to look just like a paper PCR you scanned in (versus some others I've seen full of tabs and pages where you can write endless amounts of info). In fact our base hospital makes us print out a copy and since they're rather stingy with printer paper and toner we are supposed to keep it to the one page so that one paragraph box is all we have to work with.

I do have a blank PCR from my previous job so you can see the space I had to work with, and the lack thereof to write novels for every single patient. Also I'm attaching a copy of my current official narrative writing guidance.


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## CALEMT

Jim37F said:


> so if I REALLY wanted/needed to write a second page, I'd have to start a whole second PCR and include all the other bits of header data



You don't have addendum forms to where you don't have to refill out everything? Interesting.


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## Jim37F

When I worked private companies, no we did not have special addendum/continuation forms. It was routine for all providers to use a single paragraph narrative (I was always taught chronological). Tell a story about what happened. Try not to repeat details already covered by other parts of the PCR, but it's better to be slightly redundant to provide a narrative that flows smoothly and covers what you saw and did.

I do believe the County EMS run report our paramedics use for 911 calls does have a page two that is used primarily for advanced airway attempts, resuscitation, and has space for a continued narrative. However it is my understanding that it is not routinely used for 5+ paragraph summaries of every medical or TC call and instead for unusual circumstances such as suspected abuse calls. I do know that on BLS level calls when our paramedics finish writing the narrative and give us the form they've never once used Page 2. It could be different for ALS calls where they hold onto the PCR throughout the call and then upload it to the server after transfer of care...but at my previous private company job where we needed to collect a copy of the fire medics run report to submit with our paperwork I never saw Page 2 used for a routine call.


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