AMR narritive help..
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Stupid question, but why not ask your coworkers and or partner and or supervisor?
DrankTheKoolaid
Forum Deputy Chief
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Are we talking BLS IFT or 911? Though it really should not make a difference as a well written narrative should happen regardless
Sorry it's a stupid question but it's relevant in my life.. I asked my sup but he said just use my soap format and break down.. No a lot of help.
We do transports and 911 so I use both but when it comes to a maritime it doesn't change much. I figured I'd get some more point of views I guess.. Didn't think I was being stupid tho.
We do transports and 911 so I use both but when it comes to a maritime it doesn't change much. I figured I'd get some more point of views I guess.. Didn't think I was being stupid tho.
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He wasn't calling your question stupid. I believe he was saying his question was. In any case, HaleEMT probably did have the best idea. Meds should be an easy part of your narrative, if it's even included there. With the PCR software we use, meds are a separate section and I don't talk about them in my narrative. If you do, simply include them in your subjective section as what the patient relates taking and move on.
DrankTheKoolaid
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By MEDs he is talking about AMR ePCR program
Ask your FTO... If not, google MEDS. Hell get on the portal and do the documentation training.
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I do apologize, I did not mean it as an insult. I was saying my question might be stupid, because the first place you should go is a supervisor, FTO or coworkers, but I wasn't sure if you had gotten to that phase yet. My best response is that it really is something that has to come from then not an EMS forum.
To explain what I mean, I work for two different agenies and volunteer for a third. All three use EMSCharts but like their reports written different. With meds in mind, one example is, one organization wants oxygen administration to be performed as an airway action where the other wants oxygen administration to be treated as a medication administration.
To explain what I mean, I work for two different agenies and volunteer for a third. All three use EMSCharts but like their reports written different. With meds in mind, one example is, one organization wants oxygen administration to be performed as an airway action where the other wants oxygen administration to be treated as a medication administration.
I work for AMR here in Ca and they have actually told us, with all of the information tat we have to put in to meds, your narrative shouldnt and doesnt need to be more than a line or two detailing basic interactions with patient, most of the information people put in narratives is completely redundant,
especially with meds!
unless something significant happens during the course of a call, i basically use the same narrative ive been using for almost 10 years, and I have been praised countless times for my excellent documentation skills, when it comes down to it, every call has the same flow of events, just certain differences, don't make it harder than it needs to be.
This is how I would document a simple BLS run in meds...I'm sure someone wont like it, but I think its thorough, but simple and concise, it still contains some redundant information, like stating vital signs are "within normal limits," all you have to do is look at my documented vitals, which meds makes us do, and its already there, or stating patient is a&ox4, its already in my documented meds vitals, but its what im used to, so i state it, even though its redundant information.
AMR 3106 arrived at scene to find patient semi-fowlers on facility bed alert and oriented x 4 in care of facility nursing staff(how and where I found them). Patient non ambulatory due to paraplegia. Patient has history of ESRD and requires transport to hemodialysis 3 x week(just justified to the insurance company why ambulance transportation is required and why amr can pay our paychecks). currently patient denies pain or difficulty breathing. patient presents with no signs/symptoms of illness or distress. patient vital signs within normal limits(I've basically justified BLS over ALS transport). patient transferred to gurney via transfer sheet and seated semi-fowlers for comfort(cant say I dropped the :censored::censored::censored::censored:er). patient transported code 2 bls without incident or change en route(when patient or staff sign my paperwork, they are basically confirming this). patient transferred to facility dialysis chair via transfer sheet and seated poc(I specifically state "via transfer sheet," just so AMR can't come back and say I didnt use the stupid blue "friction-less transfer sheet" that we are technically supposed to use on every patient transfer) . report given to receiving facility nursing staff and patient care transferred(I handed them off to someone else and they are no longer my problem and receiving staff sign to this effect).
Hopefully that helps a little bit, my way isnt perfect, or the "right" way, its just what works for me, at least for 98% of simple bs bls runs here in socal.
especially with meds!
unless something significant happens during the course of a call, i basically use the same narrative ive been using for almost 10 years, and I have been praised countless times for my excellent documentation skills, when it comes down to it, every call has the same flow of events, just certain differences, don't make it harder than it needs to be.
This is how I would document a simple BLS run in meds...I'm sure someone wont like it, but I think its thorough, but simple and concise, it still contains some redundant information, like stating vital signs are "within normal limits," all you have to do is look at my documented vitals, which meds makes us do, and its already there, or stating patient is a&ox4, its already in my documented meds vitals, but its what im used to, so i state it, even though its redundant information.
AMR 3106 arrived at scene to find patient semi-fowlers on facility bed alert and oriented x 4 in care of facility nursing staff(how and where I found them). Patient non ambulatory due to paraplegia. Patient has history of ESRD and requires transport to hemodialysis 3 x week(just justified to the insurance company why ambulance transportation is required and why amr can pay our paychecks). currently patient denies pain or difficulty breathing. patient presents with no signs/symptoms of illness or distress. patient vital signs within normal limits(I've basically justified BLS over ALS transport). patient transferred to gurney via transfer sheet and seated semi-fowlers for comfort(cant say I dropped the :censored::censored::censored::censored:er). patient transported code 2 bls without incident or change en route(when patient or staff sign my paperwork, they are basically confirming this). patient transferred to facility dialysis chair via transfer sheet and seated poc(I specifically state "via transfer sheet," just so AMR can't come back and say I didnt use the stupid blue "friction-less transfer sheet" that we are technically supposed to use on every patient transfer) . report given to receiving facility nursing staff and patient care transferred(I handed them off to someone else and they are no longer my problem and receiving staff sign to this effect).
Hopefully that helps a little bit, my way isnt perfect, or the "right" way, its just what works for me, at least for 98% of simple bs bls runs here in socal.
SandpitMedic
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Hx: M** -> C3 to unresponsive pt.
Sx: Per care home aid pt arrived 3 days ago, and that they have no info on her med hx. Stated that pt became unresponsive and breathing abnormally for 5 min PTA of EMS. Per FD they have no further and are engaged in tx.
Obx/Tx: AOS to 31 y/o obese female unconscious/unresponsive GCS3 supine on bed in care of FD. Pt has NPA in place, V/S stable with low BP ~90s, and irregular respiratory rate. SPo2 100%, cap refill <2 sec, ETCo2 low. O2 initially via N/C @ 6LPM followed by BVM @ 15LPM, given 2mg Narcan IN with no changes. Pt appears atraumatic except for apparent bed sores and some various bruising in late stages. IV access unobtainable via bilat EJ attempts and 1 IO miss in R tibia. Obtained adult IO in L tibia with NS volume infusion started on scene with approx 350cc administered with pressure bag throughout EMS contact with no change. ABCs intact and protected throughout contact. Pt trismus throughout contact through hyper-oxygenation and slow IV Etomidate 30mg with no changes. UTO oral intubation due to trismus; nasal intubation attempted and failed x2 after pre/post O2, 1 squeeze Neosenephrine, 1 fingertip Lido gel. Continue pt oxygenation via 2 man rescue breathing via BVM with good compliance. BS clear upper/LL with mild crackles in RL, PERRL, no JVD, Abd SNT, EKG=NSR to mild Sinus Tach, BGL=80, =/strong radial pulses, skin WPD, all other unremarkable. Pt condition remained unchanged throughout contact. Txp C3 to ****, max assist gurney->bed x4, TOC & report to ER RN/MD. NFPC.
Sx: Per care home aid pt arrived 3 days ago, and that they have no info on her med hx. Stated that pt became unresponsive and breathing abnormally for 5 min PTA of EMS. Per FD they have no further and are engaged in tx.
Obx/Tx: AOS to 31 y/o obese female unconscious/unresponsive GCS3 supine on bed in care of FD. Pt has NPA in place, V/S stable with low BP ~90s, and irregular respiratory rate. SPo2 100%, cap refill <2 sec, ETCo2 low. O2 initially via N/C @ 6LPM followed by BVM @ 15LPM, given 2mg Narcan IN with no changes. Pt appears atraumatic except for apparent bed sores and some various bruising in late stages. IV access unobtainable via bilat EJ attempts and 1 IO miss in R tibia. Obtained adult IO in L tibia with NS volume infusion started on scene with approx 350cc administered with pressure bag throughout EMS contact with no change. ABCs intact and protected throughout contact. Pt trismus throughout contact through hyper-oxygenation and slow IV Etomidate 30mg with no changes. UTO oral intubation due to trismus; nasal intubation attempted and failed x2 after pre/post O2, 1 squeeze Neosenephrine, 1 fingertip Lido gel. Continue pt oxygenation via 2 man rescue breathing via BVM with good compliance. BS clear upper/LL with mild crackles in RL, PERRL, no JVD, Abd SNT, EKG=NSR to mild Sinus Tach, BGL=80, =/strong radial pulses, skin WPD, all other unremarkable. Pt condition remained unchanged throughout contact. Txp C3 to ****, max assist gurney->bed x4, TOC & report to ER RN/MD. NFPC.