# pcr naratives



## CelphCtrl (Sep 26, 2013)

I recently just started a job and they had me do PCRs for the first day. What should my narratives look like? I am just doing IFTs and I was just restating all the Hx, Rx, from what the nurse report is, etc in sentence form really.


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## NomadicMedic (Sep 26, 2013)

SOAP is easy and there's a great tutorial here: http://theemtspot.com/2009/10/06/the-soap-reporting-break-through/


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## DrankTheKoolaid (Sep 26, 2013)

Unit number and what your paged to.  Report of on scene info. What you actually observed and are told by pt.

Pertinent positives and negatives. PE, treatment.

Any changes enroute, radio report to. Pt transferred to, report and belongings to. No further pt contact. License number


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## medichopeful (Sep 26, 2013)

I do a modified SOAP.  It looks something like this:
---
What we were dispatched to.  How patient was found upon arrival.  Who else was on scene/who we got report from.  ABC status, GCS, etc.

(Subjective): Information the patient/nurse told me, etc..  Information found in the chart could go here too, if it was subjective info.

(Objective/assessment): (I combine them).  Brief description of what the patient  looked like, how they were dressed, how they were conversing, level of distress, assessment findings, sometimes vitals (other times I just put that in the "vitals" section of the ePCR), etc..  Not all of this is there for every patient, you have to tailor it.

(Plan): What we did, sometimes how they reacted to treatment (other times I put that into the section above).  I put in extrication, how they were secured (on stretcher with straps x5, for example).  Who I gave report to, and that care was transferred.

I finish up with "EMS Clear.  End report (ASmi)*"
---
*First initial, first 3 letters of last name.  That way I know it's my report.  That being said, Andrew Smith is the example I used here, and it nowhere close to my real name.


This is a BASIC outline.  All calls are different regarding information in them.

Keep in mind they don't have to "flow" like a novel if you're doing SOAP method.  Get the information in there, be succinct.  Use proper grammar and syntax (and spellcheck!).  Make it readable, but don't use beautiful wording and imagery!

Hope that helps!


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## unleashedfury (Sep 26, 2013)

I do a method that was taught to me along time ago. I've done it so many times that I just have it in my head and it flows 

Dispatch - Medic 1 dispatched via (your county) 911 to (the location) for (what the dispatch is) Unit responded emergent mode with a crew of 2 from main station. Addiontal Dispatch info states a (whatever they say here ours will give us additonal about pt. complaint history and the hospital destinaiton) 

Arrived on location to find a (age and sex of patient) sitting or lying how with a complaint of (chief complaint) 

Chief Complaint

HPI - Pt. states "use quotations for pts interpretations" and paint your OPQRST picture here. including pain ratings and the any pallatives or self administered treatment by patient before 911 (pt. states he had taken 3 nitro prior to notifying EMS with no relief) 

Assesment - Start with GCS and LOC. work your way down. 

Treatment by layperson or fire or other EMS providers prior to arrival 

Treatment by You

Transport including hospital notification. any changes to pt condition good or bad and to interventions. Arrival of ED where you took the pt. and gave report to. last set of vital prior to transfer of care

and then I sign my report to end it with my initals 

UF - EMT#123456


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## EMT B (Sep 27, 2013)

Rather than starting a new topic, will just ask my question here. Back in Maine we use computers to write our reports so I don't have to worry about space in my narratives. The service I run with here in West Virginia still useses paper reports. I need help trying to figure out where I can condense my report. Here is what a normal report looks like. 

Dispatched via 911 to [location] for a [age] year old [sex] with [dispatch reason]. Arrived on scene to find the pt [mental status] with [airway breathing circulation status]. [description of how pt got onto the stretcher]. 

HPI
PMHX

HEENT
Neck
Chest
Cardiovascular
Respiratory
Back
Abdominal
Pelvic
GI/GU
Extremities
Skin

[description of interventions]
[description of change in patient presentation]

[description of how the pt got from stretcher to bed]. Report was given to [staff member] and transfer of pt care was complete.


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## FiremanMike (Sep 28, 2013)

CelphCtrl said:


> I recently just started a job and they had me do PCRs for the first day. What should my narratives look like? I am just doing IFTs and I was just restating all the Hx, Rx, from what the nurse report is, etc in sentence form really.



Some people like soap, I like a story type narrative, but tbh it kinda follows soap..

My narratives are generally like this

Pt is an 49 year old male c/o chest pain.  Patient presents AOx3 c/o chest pain which started approximately 45 mins prior to arrival and without provocation.  Patient also complains of shortness of breath and some nausea, states pain does not radiate anywhere at this time.  Patient states pain is 10/10 and nothing he has done has changed his pain at all.  Physical exam shows pale and diaphoretic skin, otherwise negative.  Patient denies previous cardiac history.  12 lead shows a sinus tach with elevation in inferior leads and reciprocal depression in lateral leads, v4R is negative.  Vitals and care as above, patient states pain decreased from 10/10 to 5/10 after initial dose of nitro, noted no changes after subsequent doses.  No other changes en route, patient transferred to University ER without incident, verbal report given to ED RN.


The most important thing to remember is to document chief complaint, relevant assessment findings, make some mention of your treatments (for me it is listed elsewhere in my report so I generally don't double document) and definitely any response (or lack thereof) to your treatments.  I like to always note in there that a verbal report was given to the ED RN, it was recommended to us years ago during some legal lecture so I just stuck with it.


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## unleashedfury (Sep 29, 2013)

EMT B said:


> Rather than starting a new topic, will just ask my question here. Back in Maine we use computers to write our reports so I don't have to worry about space in my narratives. The service I run with here in West Virginia still useses paper reports. I need help trying to figure out where I can condense my report. Here is what a normal report looks like.
> 
> Dispatched via 911 to [location] for a [age] year old [sex] with [dispatch reason]. Arrived on scene to find the pt [mental status] with [airway breathing circulation status]. [description of how pt got onto the stretcher].
> 
> ...




Is it the bubble style charts where you fill out pt. demographics and basic info and fill in bubbles to correspond like the old tests? If so if they have a PMHx Allergies and Meds section use those and skip it out of your narrative. You could probably condense your Assessment section into a paragraph format.


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## Handsome Robb (Sep 30, 2013)

Our ePCR software has a lot of drop down menus and bubbles that are used to generate a narrative that we then add subjective information into it. All my treatments and what not are in a flow chart that's imported into that narrative when I generate it. When it's all said and done our charts look something like this. There are a lot more random proprietary things that it adds that I can't remember and don't care to type but I'll get you an example.

Upon arrival we find a 65 year old male PT laying supine on the floor of the bathroom inside the home at the above noted address in obvious severe pain with FD personnel already on scene. PT is A&Ox4 with a GCS of 15 and complains of 10/10  left hip pain. The pt states he was getting out of the shower when he "slipped and fell on the wet floor" and landed on his left hip. He states he felt a "pop" when he hit the ground and had an immediate onset of severe "sharp, stabbing" pain which he rates at a 10/10. The pain is exacerbated by any palpitation or manipulation of the patient and is not relieved by anything. The pt states he would like to be transported to XXMC for further evaluation and treatment. The pt denies any recent illness or medication changes, LOC, head/neck/back pain, chest pain, palpitations, shortness of breath, abdominal pain, numbness/tingling or any other associated complaints before or after the fall. An IV is established and the PT is premedicated with IV fentanly and versed. The pt's bloomsbury sedation scale (BSS) is reduced to a -2 and the pt is scooped onto a scoop stretcher and carried to the gurney where he is placed supine and the scoop stretcher is removed. The pt is moved to the ambulance where his BSS progressively improves to a 2. The pt now states his pain is a 5/10. The pt is transported to xxMC with the changes noted below en route. The pt is lifted from EMS gurney to XXMC ER bed with the assistance of ER staff and a slide board and Pt care is transferred to ER RN. 

Changes en route to hospital:
Pt complains of "spikes" in his pain secondary to bumps in the road. He now rates his pain a 8/10. Pt is remedicated with fentanyl and states his pain has been reduced to 4/10, BSS reduced to a 0. Upon arrival to XXMC BSS +1. No further changes in assessment or pt complaint during transport. 

Physical assessment: (This is a drop down attached to a flow chart selection that is imported into the final copy of the chart

Head: PERRL at 4mm, no JVD, trachea midline, no signs of trauma, no drainage, no crepitus or step-offs noted during palpation of C-spine

Chest: No signs of trauma, equal rise and fall, CTAB, no sub-q air or crepitus noted

Abdomen: Soft, non tender, no signs of trauma, no palpable or pulsating masses noted, no discoloration. 

Pelvis: Stable, deformity to left hip noted, no incontinence. 

Extremities: Shortening and external rotation of left lower extremity, crepitus noted in proximal thigh, +CMS. All other extremities unremarkable.

Back: No signs of trauma, no crepitus or stepoffs noted or pain reported during palpation. 

Neurological Awake, Initial GCS, Final GCS, Pupils

Respiratory: Breathing rate and quality, lung sounds

Cardiovascular: Skin signs, presenting rhythm and rhythm upon arrival to ER, cap refill

Flow chart:
PTA Pulse oximetry
PTA Nasal Cannula Oxygen 2.0 LPM inhalation
22:00 ALS Assessment
22:00 Urgent Care Assessment - Not appropriate for Alternate Destination - requires IV analgesia, possible complex fracture/dislocation requiring surgical intervention. 
22:01 Comfort and Re-assurance
22:02 Explanations to Patient provided
22:02 IV 1st, right forearm, 20g, 1000cc bag of NS TKO
22:03 ECG Monitor
22:03 ECG Interpretation Sinus rhythm without ectopy
22:03 BSS Assessed +3
22:03  Zofran 4.0 MG Intravenous
22:03  Versed Bolus 1.0 MG Intravenous
22:04  Fentanyl Bolus 100.0 MCG Intravenous
22:06  Re-assessment - BSS reduced to -2, pt placed on scoop stretcher and moved to gurney. 
22:08 Seatbelts applied
22:10 Re-assessment BSS now +2, Pt complains of exacerbation of pain secondary to bumps in the road, rates 8/10.
22:11  Fentanyl Bolus 100.0 MCG Intravenous
22:15 Re-assessment Pt states pain reduced to 4/10m BSS reduced to 0
22:20 Re-assessment BSS now +1. No other changes from previous re-assessment upon arrival to XXMC
22:20 Total Fluids In 0.9% NS 150 ML Intravenous

Vitals would be put in in a drop down menu and imported. Same with history, allergies and medications

This is a real basic look at what they look like. Our charts are generally about 3 pages printed if its BLS or ILS. ALS with ECGs attached can easily be 5+

Our transfer charts generally look like this. I wont do the exam and what not just hte narrative part. 

Upon arrival we find xx year old pt laying in bed at xx ER. Pt presented to ER at xx time complaining of xxx. Pt was diagnosed with xxx and is being transferred to xx hospital for xxx services which are note available at the sending facility. The pt was premedicated by staff PTA of EMS and denies any acute complaint. Pt is lifted onto EMS gurney, placed in poc, moved to the ambulance and transported to xx facility without (or with) changes. pt is lifted from EMS gurney to XX MC bed and Pt care is transferred to XXMC RN.


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## Jon (Oct 1, 2013)

Hey EMT B - you're asking how to condense your narrative. Simple answer - don't repeat stuff.

Your form already establishes what unit you're on, and often PMH/Meds/Allergies are already included too. No need to repeat them. My "transport" narrative is often very short:

EMS is taking pt to____ for ____. Pt found____, placed on stretcher with draw sheet. Verbal report from RN. Pt on EMS Cardiac monitor. Pt placed in ambulance, transported without incident. At destination. Pt brought into ____, placed on bed by draw sheet. Care/info transferred, verbal report to RN. Crew available without incident.


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## unleashedfury (Oct 1, 2013)

Jon said:


> Hey EMT B - you're asking how to condense your narrative. Simple answer - don't repeat stuff.
> 
> Your form already establishes what unit you're on, and often PMH/Meds/Allergies are already included too. No need to repeat them. My "transport" narrative is often very short:
> 
> EMS is taking pt to____ for ____. Pt found____, placed on stretcher with draw sheet. Verbal report from RN. Pt on EMS Cardiac monitor. Pt placed in ambulance, transported without incident. At destination. Pt brought into ____, placed on bed by draw sheet. Care/info transferred, verbal report to RN. Crew available without incident.



I'm a huge believer in this. The first half of the chart with the drop down menus gives you all the pt info complaint hx meds allergies and where you were dispatched to. 

However the QA nazis got some sort of gurus about how you must have a novel for a narrative that tells the entire call from beginning to end. I never understood this as its like why waste my time filling in the rest of the chart if I have to type it up anyways? I'm all about effeincy


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