# Patient Narratives



## StretcherFetcher (Apr 7, 2017)

What formula or strategy do you all use to write your patient narratives? I'm starting my second week on the job and I'm struggling to find a consistent theme to use.

Any mnemonics  ?

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## NomadicMedic (Apr 7, 2017)

There'a a bunch. CHART and SOAP are the two most common.

Try this thread.
https://emtlife.com/threads/post-examples-of-pcr-narratives.16135/

and this:

http://www.lifeunderthelights.com/2...e-today-to-improve-your-ems-narrative-report/


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## DesertMedic66 (Apr 7, 2017)

I use a chronological order. So I describe the call as it played out. For me it flows better and makes a nice story.


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## Jim37F (Apr 7, 2017)

Ask 20 different providers, you'll probably get 20 different answers......FWIW I personally like chronological narrative myself "Dispatched to this, found this patient in this way, complaining of X, Secondary to Y, History of Present Illness/what happened, Pertinent positives/negatives, History, Allergies meds (though those are listed elsewhere on our form so I'll usually only mention the HAM if it's directly pertinent to the CC and/or treatment), Treatments rendered, transported to A Hospital for B reason, any changes" is a basic flow....basically just tell the story of what happened.


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## FLMedic311 (Apr 7, 2017)

What those guys said! Chronological


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## RocketMedic (Apr 7, 2017)

I really like soap. Used it for years. Smells good. Duke Cannon is my friend.


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## SpecialK (Apr 8, 2017)

PMHx/SHx/FHx as appropriate
HPI/CO
O/A
O/E 
Impression/diagnosis
Plan

If it is decided to both refer somewhere AND transport there then "enroute" too.


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## Akulahawk (Apr 8, 2017)

In the past I have used primarily SOAP, CHARTED, and chronological methods of charting. What I've found is when your brain just doesn't want to work, chronological works quite well because you're basically retelling the story of your patient contact from start to finish. It is lengthy but easy to learn and use otherwise. When I do a SOAP (or SOAPIE) note, it's NOT like doing an H&P because the focus is on the story, my exam, etc. It's not exactly easy to learn but it works for me. 

There are tons of other methods out there for charting but the one that simply sprains my brain (think result of a Chihuahua imaging the sound of one hand clapping) is PIE. This is Problem, Intervention, Evaluation. It skips a lot as it's basically charting by exception. 

In my ED, we do Chart by Exception. While we do look at all systems, we FOCUS on the primary problem and go from there. CBE drives me nuts because to truly do this, if there's NOTHING wrong with the patient, your chart would be nearly blank. For the speed necessary in the ED, CBE is very much an advantage. 

For one of my employers, they disliked me doing SOAPIE notes because I was pretty much the only one using it (our transport nurses did too, but they were special...) and the billers weren't used to seeing documentation done that way. They didn't stop me from using it though. That was back in the days of paper charting, so I had much flexibility in how I documented stuff.


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## Flying (Apr 8, 2017)

I write chronologically/follow the call. Generally goes complaint > history > assessment > interventions w/ justification.


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## NomadicMedic (Apr 8, 2017)

I actually write a chronological, in a modified SOAP. It's how our old software worked, and now it's how I write 'em without even thinking. 

I rarely include any of the vitals or assessment points in the narrative, as they're all marked in the flow directly above my text block. Obviously if something changes or is of significance, I note it. 

It's a little goofy, but I've been doing it that way for years and nobody ever complained.


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## GMCmedic (Apr 8, 2017)

I use a CHART in a chronological way. Ive done it since I started but it evolves regularly. 

Were given the freedom to do what makes us feel comfortable. Our director tried to change us to timeline narratives in EMscharts cause thats what the precious flight crews do. He eventually gave up. 


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## Ensihoitaja (Apr 8, 2017)

I write an HPI-like format. 

Pertinent dispatch info
HPI (history of the present illness)
meds, history, allergies, family history, social history

Review of Systems (General, Head/eyes/ears/nose, neck, cardiovascular, respiratory, abdomen, GI/GU, skin, neuro, psych, musculoskeletal)

Objective (Same as ROS but without psych)

Plan with all treatments, transport info, vitals, etc, done in chronological order


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## EpiEMS (Apr 9, 2017)

@Chase and @Akulahawk, do you find your charting methods influenced by your nursing education?


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## Akulahawk (Apr 9, 2017)

EpiEMS said:


> @Chase and @Akulahawk, do you find your charting methods influenced by your nursing education?
> 
> 
> Sent from my iPhone using Tapatalk


I haven't been in the field in quite a while. That being said, I wouldn't change my charting even though I'm a nurse. If anything, my nursing charting has been more influenced by my Paramedic education and experience...


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## Tigger (Apr 10, 2017)

I do the SOAP thing. Our software has a whole page for assessment that includes free text spacing for all systems, so I just say "See assessment tab of this ePCR." The plan is more of a chronological overview of the call, to include treatment (with justification and result), how the patient was moved, and what (if any) changes occurred during txp.

I hate the AMR Meds Objective section and don't really use it. Instead I write out a whole review of systems in the Objective portion of my note. ESO is much better.


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## S911S (Apr 13, 2017)

Pertinent negatives help a lot with BLS reports, especially since usually there is a lot NOT wrong with them on BLS rides lol
 "Denies pain in blank, blank, blank, etc". No SOB. No LOC. No n/v. Also it helps support that it's a BLS ride and not als.


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## soflomedic14 (Apr 14, 2017)

SOAP for sure. Easy and to the point


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## EpiEMS (Apr 14, 2017)

Tigger said:


> AMR Meds Objective


Never heard of this...what's it asking for?


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## Tigger (Apr 14, 2017)

EpiEMS said:


> Never heard of this...what's it asking for?


Meds is the PCR program, objective is just a tab.


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## EpiEMS (Apr 14, 2017)

Tigger said:


> Meds is the PCR program, objective is just a tab.



Ah, ok, gotcha. My lack of knowledge here is perks of not having worked for the 'evil empire', I guess


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## NPO (May 14, 2017)

> Response info

> What I found
> What I found after a better look

> What I did about

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## NomadicMedic (May 14, 2017)

NPO said:


> > Response info
> 
> > What I found
> > What I found after a better look
> ...




Very funny. Mine is similar now. 

Response info. 

What they told me. 

What I saw. 

What I did.


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## dutemplar (May 15, 2017)

They're pushing the APs towards an IMIST-AMBO for turnover reports and where narratives are still used.

Completely irrelevant, but something I recall seeing years ago:
You didn't have a narrative.  You submitted a large, awkward, random assemblage of sentences.  If true, the sentences were kidnapped in the dead of night and forces into this violent and arbitrary plan of yours clearly against their will.  Reading your narrative was like watching unfamiliar, uncomfortable people interact at a cocktail party that no one wanted to attend in the first place.  You didn't submit a narrative.  You submitted a hostage situation.


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## Ewok Jerky (May 15, 2017)

SOAP

S: what the patient tells you. 
O: objective findings including what you see and smell, the scene, vitals, physical exam, moniter.
A: 1 sentence summary
P: your treatment including intervention and transport decision.


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## Hold My Beer (May 15, 2017)

Ask your QI/QA what method they prefer. I always used SOAP back when I still used paper reports.  I loved chronological but my QA/QI department has since forced SOAP on us. Lame.


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## NomadicMedic (May 15, 2017)

Hold My Beer said:


> Ask your QI/QA what method they prefer. I always used SOAP back when I still used paper reports.  I loved chronological but my QA/QI department has since forced SOAP on us. Lame.



I could never understand why people got bent out of shape over things like the documentation standard. It's how they want it done. And really, who cares? 

If it helps QI get through the charts and helps billing increase the reimbursement, I'll write em any damn way you want.


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## EpiEMS (May 15, 2017)

I'll write it any way they want...they just have to tell me how they want it written. Took me a while to get my agency's standards down...because nobody has written them down clearly. 


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## StCEMT (May 15, 2017)

NomadicMedic said:


> I could never understand why people got bent out of shape over things like the documentation standard. It's how they want it done. And really, who cares?
> 
> If it helps QI get through the charts and helps billing increase the reimbursement, I'll write em any damn way you want.


Probably annoyance. I don't particularly care, but it is going to take me a bit to make sure I remember all the bullet points of DACHARTE after having been writing chronological.


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## planetmike (May 17, 2017)

StCEMT said:


> Probably annoyance. I don't particularly care, but it is going to take me a bit to make sure I remember all the bullet points of DACHARTE after having been writing chronological.



What is the first A in DACHARTE?


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## StCEMT (May 17, 2017)

planetmike said:


> What is the first A in DACHARTE?


Arrival. What you saw, pt location, other units on scene etc


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## Harleyjon (Jul 2, 2017)

What I do is kind of SOAP and kind of Chonological. Dispatched to, on arrival found, bystanders and Pt stated, T/P requested, Hx, meds, allergies, Tx: vitals, interventions/responses, report called in/ any orders, Pt conditon/changes during T/P, arrival at ED. When I started I formed my own system and I would read all the reports I could get hold of and slowly tweaked it here and there as I went along. The one thing I have done is try to write every report the same way as I have been going along. By doing this I find it easier to make sure I have not forgotten anything. So far this has worked for me.


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## DrParasite (Jul 7, 2017)

If you ask 10 EMS workers what the best charting method is, you will probably get more than 10 different answer.  Throwing in QA/QI, billing, your FTO, your medical director, paper vs electronic, state requirements, and you can see where it all goes to ****....

DrP's rules for charting: 1) if your agency has a specific way they want to chart, and everyone follows the same method, than that is the way you write your chart.  If your agency says one thing, and someone else say otherwise, (FTO, billing, etc), than they need to have a chat so you are all on the same page, and get back to you on how the "agency" wants it done, and then the agency needs to then make sure that everyone is on the same page.

2) paper charting and electronic charting are done different.  the content might be the same (and should be), but the method of charting is different.  in some electronic charting systems, you shouldn't have a traditional narrative.

3) If no requirements are provided (and no, my FTO's opinion doesn't count) I do chronological, for the simple reason of it's how my brain works, and if I get called into court / medical review / medical directors office / supervisor's office over something, I have my documentation the way I want it, complete, and easy to review.  

Day 3 of paramedic school, the local county EMS deputy director was giving a lecture on documentation, going over charte, soap and another one that I can't remember.  then she gave a demonstration of a scenario, and the students were supposed to document what happened. when she asked us to give our narratives, I gave mine, using my chronological flow, entirely from memory, because that's how my brain likes to record things.  

It's not rocket science, but it does take practice, and repetition is the best way to accomplish it.


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