BlS Narrative Templates

[62_derick]

I am new to ems world and just started a job about a month ago. I am getting confortable with talking to the patients and doing my skills. However I am still having some issues with writing out my narratives and also radio reports. I have asked some of the people that I work with and I get a different answer from each one.

When I went over our trip sheets they told me to do my narrative short and sweet, I dont really think that is a proper way of doing one. I have been on the fire side for a while and doing narratives for them so its different with the ems side.

Now my question is does anyone know if there is a template I can follow or if anyone could give me some ideas on what to write in my narrative?

Thanks

 

[Dominion]

I had never heard of this when I first started, but naturally started writing my run reports this way. I use CHART, the way it was explained to me was the following:

Chief Complaint: Kind of your general impression/what the patient says is wrong, I've always written this as something like: "32 yo male(or female); c/o SOA, patient states "I just can't catch my breath" in two word bursts"

History/Event: Include any past pertinent medical history, history of the event/onset.

Assessment

Rx: Treatment, what did you do. This is anything from positioning the airway or patient, giving breathing treatments, whatever you do to try to alleviate the problem.

Transport: Where you took them, report called in? ETC

The last section I save for changes such as maybe...."After O2 and positioning the patient stated relief..blah blah blah blah".

 

[fiddlesticks]

i hate PCRs so im not much help but for patches i write my vitals, RX and pt sex/age and CC. on a note pad then have that to keep me on track and keep it short, they put the mic down after the first 2 mins.:sad:

 

[cm4short]

I hate narratives too. Too make matters worse, we now use paper PCR's so we can't just scribble anything anymore.

I found this the most helpful in doing the PCR... make a fill in the blank diagram which covers the basics; AND STICK TO IT. be sure to enter any special information when it applies.

Mine starts of... AOS(arrived on scene) to find pt lying __at __. Pt is a __year male/female pt weighing approx__ with c/o __. Pt has secondary c/o__ secondary to__.... I continue describing patient condition on arrival(ABC's, GCS...)... Treatment rendered. Transport&treatment and all changes up to turn over of care.

I just gave a brief example. You have to do what works for both you and your system.

For radio contact info: look in your protocol manual. It spells out specifically what's required for radio call-ins. I can range from minutes to seconds depending on where you work.

 

[46Young]

Are you 911 or IFT? There are important differences between the two.

 

[lightsandsirens5]

I use a little "cheat card" that has our SOAP/Sequential narritive points on it. It is at the shack right now but I'll get you a copy of it next time I go in. As for the radio patch, we also have a card in each rig with the format on it. I'll get that to. It goes something like this:

________(Facillity) this is ______(unit #).

(Reply from facillity)

We are currently _________(minutes) out from your facillity with a(n) _______(age/gender) pt. __________(injury/illness. Describe pts condition).
Vitals currently are B/P_______, Pulse ______(Reg/Irreg), Respirations ______(Reg/Irreg), SPO2 is_____% on______(R/A, O2 15 L NRB, 3 L NC, etc). Moniter shows______(rythm).

______________________________(Proceedures done. Full spinal precautions, O2, IV, blood braw, BGL, bleeding control, etc. And Meds: what, when, how much, etc.)

ETA is now ________(restate ETA). Do you have any questions or orders?

 

[Akulahawk]

I use a little "cheat card" that has our SOAP/Sequential narritive points on it. It is at the shack right now but I'll get you a copy of it next time I go in. As for the radio patch, we also have a card in each rig with the format on it. I'll get that to. It goes something like this:

________(Facillity) this is ______(unit #).

(Reply from facillity)

We are currently _________(minutes) out from your facillity with a(n) _______(age/gender) pt. complains of: __________(injury/illness).
Describe pts condition - describe significant findings on secondary exam.

Vitals currently are B/P_______, Pulse ______(Reg/Irreg), Respirations ______(Reg/Irreg), SPO2 is_____% on______(R/A, O2 15 L NRB, 3 L NC, etc). Moniter shows______(rythm).

______________________________(Procedures done. Full spinal precautions, O2, IV, blood braw, BGL, bleeding control, etc. And Meds: what, when, how much, etc.)

ETA is now ________(restate ETA). Do you have any questions or orders?

That's pretty close to how I did my hospital notifications... modified in red for something even closer.

 

[Akulahawk]

As to charting methods, the CHART format works pretty well, SOAP (and variants) does too. In the past, I've also used HIPS or HOPS charting. A chronological narrative is easy to learn and master, however, it's also very lengthy.

I'm much more familiar with SOAP type charting, so I typically will do my reports in that format, or something close to it.

• S-Subjective - whatever the patient/bystanders tell you
• O-Objective - signs/symptoms/observations made by you or your team
• A-Assessment - what you think is wrong with the patient
• P-Plan - how you plan to treat the problem(s)
• I-Intervention - measures you've taken to achieve an expected outcome
• E-Evaluation - an analysis of the effectiveness of your interventions (did it work?)
• R-Revision - any changes from the original plan of care.

Depending upon the exact format of the PCR, certain parts of the above might be charted in different areas, so your interventions might be a list of procedures you've completed, and may have a "response" section, which takes care of the evaluation portion to a large degree, as well as revisions...

 

[eveningsky339]

I learned CHART, and it didn't take me too long to become comfortable with. SOAP is pretty useful as well.

 

[Dominion]

I've never been a huge fan of SOAP, when I first learned to write reports I did it on my own, then later was shown CHART. When I started paramedic class we were introduced to SOAPIER during our documentation class and had to write up 5 scenarios in each style. I found CHART flowed much easier....for ME. It's different for everyone and you need to develop your own style, as long as it makes sense and you get all the required info you'll be fine.

 

[Lifeguards For Life]

Dom, i was just about to post SOAP. I personally find the CHART method to flow easier

 

[Bloom-IUEMT]

Don't forget pertinent negatives when you do PCRs. I've always been told that if you didn't document it you didn't look for it. Example: pt no c/o loss of consciousness, pt no c/o altered mental status, no c/o pain, no c/o SOB, no obvious trauma, no bleeding, no change in physical condition en route, no change in mental status en route, etc. etc. I always try to err on the side of too much detail.
Also, document lifting technique--ie moved from bed to stretched by bed sheet lift, pt ambulated from chair to stretcher with/without assistance.
I tend to leave out vitals just because we document them separate from the PCR in our run sheets.

And IDk if this just for my service but I was told to keep it short and sweet when contacting the receiving facility. Name, DOB, c/c, NOI/MOI, if they're in spinal immobilization, if there is loss of consciousness, major trauma, significant hx if pertaining to c/c, and ETA. I tend to leave out vitals for my BLS pts unless they are a cause for concern. I give the more detailed report to nurse in ED. But I ALWAYS ask "Any other info you'd like at this time?"

 

[Lifeguards For Life]

some recieving facilitys want the bare essentials; CC. pulse, b/p resp, sp02. interventions, any remarkable findings and ETA. Then some hospitals want a biography of sorts. I think keeping it super simple is generally the best policy

 

[EMTinNEPA]

Let me know whether you work IFT or 911. I can provide templates for either.

 

[62_derick]

I do both IFT and 911!

Thanks for all the help now if I can get a call so I can use it.

 

[Ridryder911]

I have been teaching documentation and re-enforcing for the past month. We officially went to the CHART method except for one individual whom can document outstanding with the SOAP method.

Personally, I like the SOAP method for in-hospital as I see it can apply much more than in the pre-hospital setting. For example, "Plan" is very hard to describe as in short term and then double document as the treatment. Again, in the hospital environment I would be able to make long range plans such as ....."repeat ABG's in 1 hour and re-evaluate current ventilator settings"...

I too believe that the CHART method is much more simple and as one that TQI about 50-100 charts a day, can definitely state that it is much easier to read and covers the material if one follows it.

I do ask though, all states are supposed to adapt to NEMSIS standards and be reporting them to their State and National liaison. There are at least 40-60 fields that has to be completed or will not be accepted or kicked back as incomplete. I am surprised I have not heard of more discussion on this....

R/r 911

 

[SoCal]

________(Facillity) this is ______(unit #).

(Reply from facillity)

We are currently _________(minutes) out from your facillity with a(n) _______(age/gender) ALOC and GCS_______ pt. C/C __________(injury/illness. Describe pts condition).HAM___________ Any Pertinent info. ____________
Vitals currently are B/P_______, Pulse ______(Reg/Irreg), Respirations ______(Reg/Irreg), SPO2 is_____% on______(R/A, O2 15 L NRB, 3 L NC, etc). Moniter shows______(rythm).

______________________________(Proceedures done. Full spinal precautions, O2, IV, blood braw, BGL, bleeding control, etc. And Meds: what, when, how much, etc.)

Do you have any questions or orders?

So a quick radio report would go:

"St. Mary's this is Unit 6 with pt. information.

Unit 6 go ahead.

Good Morning St. Mary's this is Unit 6 currently enroute to your facility with a 10 Min. ETA On board we have a 45 y.o. Male A&O GCS 15, C/C of SOB progressively worsening over 1 Hr. Our Pt. has a history of asthma, HTN. Our pt. has no allergies, and meds will be provided upon our arrival. Our pt. has a B/P of 134/74. RR 26 w/ Audible wheezes. HR 88 No ectopy shown on the monitor. SPo2 94 on Neb. at 8 Lpm.

We have an IV established and we have an albuterol treatment running.

Do you have any questions or orders?"

 

[SurgeWSE]

Here's the computer narrative from a run I just did. I tend to be long-winded, but I'd rather over do my documentation (I've been subpoenaed for several calls, mostly DWIs and domestics, that were between 2 and 4 years old). This is essentially CHART. I don't include times in the "Treatment" section because meds/procedures are documented with times at another location in the software.

EMS RESPONDED IMMEDIATELY TO "CHEST PAIN." EXTENDED RESPONSE BECAUSE OF DISTANCE. FOUND ** YEAR OLD MALE SITTING UPRIGHT ON CHAIR APPEARING IN PAIN. PT C/O 2 DAY HX OF "LIGHT CHEST PAIN" WHICH INCREASED SUDDENLY TO 10/10 TODAY. PT STATES PN RADIATES TO LUE, DESCRIBES AS "CRUSHING," DENIES PROVOKING PALLIATING FACTORS. STATES PRESENT PAIN IS IDENTICAL TO PREVIOUS MI'S, C/O DYSPNEA, PRODUCTIVE COUGH, VOMITED X 1 YESTERDAY.

ASSESSMENT SHOWS AN ~60 KG WHITE MALE AOX3, GCS=15, SKIN PINK/WARM/DRY. HEENT ATRAUMATIC AND NORMALCEPHALIC, JUGULAR VEINS FLAT. CHEST ATRAUMATIC, LUNG SOUNDS MILD, SPORADIC RHONCHI, PN NOT REPRODUCIBLE. ABDOMEN TENDER TO PALPATION AT UPPER MIDLINE (STATES PN IS DIFFERENT FROM CHEST PAIN). PELVIS AND BACK EXAMS DEFERRED. MOVES ALL EXTREMITIES WELL, 2+ PEDAL EDEMA BILATERALLY. REMAINDER OF EXAM UNREMARKABLE.

PRIOR TO ARRIVAL, PT HAD NTG X 2, ASA 325 MG PO, O2 AT 3 LPM/NC, EMS TREATMENT INCLUDED ALS ASSESSMENT, EKG SHOWS SINUS RHYTHM/NORMAL AXIS/SLIGHT ST DEPRESSION INFERIORLY (NOT DEFINITIVE, BUT CONCERNING GIVEN OVERALL CLINICAL PICTURE), #18 IVAD PLACED LEFT HAND WITH NS FOR 500 ML BOLUS, 2 MAN CARRY TO COT, TRANSPORT IN POSITION OF COMFORT, MORPHINE 5 MG IVP WITHOUT CHANGE, NTG 400 MCG SL Q 5 REPEATED X 8 WITHOUT CHANGE, ATTEMPTED 2ND IVAD WITHOUT SUCCESS, SERIAL EKGS WITHOUT CHANGE, CONTACTED DR. ****** AT ******** AND RECEIVED ORDERS FOR CONTINUOUS NTG Q 5 AND MORPHINE TITRATED TO PAIN/VITAL SIGNS FOR AN UNLIMITED AMOUNT, MORPHINE 2 MG IVP WITHOUT CHANGE, MORPHINE 3 MG IVP WITHOUT CHANGE, MORPHING 4 MG IVP WITHOUT CHANGE, SUPPORTIVE CARE.

TRANSPORTED WITHOUT RLS TO ****** (PT REQUEST) WITHOUT INCIDENT. REPORT TO ED STAFF.

One thing I would recommend (something on which I am working) is avoiding the abbreviations I've used. These narratives are transcriptions of my hand-written narrative, so I default to abbreviations for brevity when I probably should not.

As for radio call-ins, I've worked in the clinical setting long enough to know that I don't hear anything past the first sentence, so I tell my students that if it's important, it had better come out in your first breath.

Mine typically go:

Medic ** in-bound non-emergency with ** year old male complaining of 2 day history of chest pain and dyspnea which increased to 10/10 today. EKG shows inferior ischemia, no apparent infarct, vital signs unremarkable. Pt has received Apirin/Nitro/Morphine without relief. We'll be at your facility in 7-10.

If they want more, they'll ask.