Differentiating between history and treatment in the narrative.

[Aidey]

My company has been implementing some changes to how they want us to chart, and I've run into a situation I'm not sure how to address.

At what point does information become treatment rather than history of the present illness?

Example:

The patient is a 30 year old male who was the restrained driver of a full sized pick up truck that hit a brick home head on. The vehicle was traveling about 50mph. There was front air bag deployment (etc). **The driver's side door was removed and the dash pushed forward to extricate the pt. A c-collar was applied, and the pt was placed in a KED and slid onto a backboard.**

Now, is that last bit HPI or treatment? Or both? Which part of the narrative does it get documented in?

 

[Amycus]

Treatment would begin at "a c collar was applied" or whenever you document manual stabilization was taken. Whichever came first. The latter I'd assume being true.

 

[DrParasite]

HPI is everything that happened before your got there. as well as any pertinent negatives or answers to questions you had for the patients.

the narrative (or activity log) starts the moment you do an intervention.

in your case, I would put that the patient was entrapped in the vehicle, and the fact that you were there while the FD extricated the patient all goes in the activity log.

 

[Aidey]

Activity log? I have never heard that before.

 

[DrParasite]

an activity log is used at my agency instead of a narrative for our online charting, because it gives a flowchart with time stamps, so you can say at what time you did what, and what the patient's condition was.

so you can time stamp when you started the IVs, began CPR, intubated, spoke to the doc, changed your assessment from abdominal pain to diff breathing because the patient suddenly complained of the new chief complaint, etc.

 

[marineman]

I use RCHART (standard CHART with R being response info) but I apparently do it differently than most. I would leave anything done to gain access to the pt to start my assessment as the history. The assessment includes any abnormalities and my treatment for them since often we will treat an abnormality as we assess it. My treatment is a list rather than full detail of the treatments since I already did that in my assessment section. To me it improves the flow of the narrative. Using your example here's how I would word it.

H- The patient is a 30 year old male who was the restrained driver of a full sized pick up truck that hit a brick home head on. The vehicle was traveling about 50mph. There was front air bag deployment (etc). **The driver's side door was removed and the dash pushed forward to gain access to the pt.

A- *bunch of blah about initial assessment*... Due to mechanism manual C-spine stabilization and cervical collar are applied immediately. *any other notes of rapid assessment if you do them before moving pt*. Pt is extricated using a KED to transfer pt to LSB (long spine board if you don't use that particular abbreviation). *CMS checks, additional assessment details blah blah blah*

It's your report, you're the only one that will have to defend it on the stand. Write it however it makes sense to you. I am known for writing very lengthy and detailed reports but should I ever have to defend one in court I know that I won't have to pull any details from the old memory bank because they're all right there in my report.

R- Extrication w/ full immobilization using KED, LSB, and C-collar. IV. Needles to eyes, etc.

 

[mycrofft]

Yes, treatment is what is done for/to/about the pt on your watch.

History is hearsay (or "subjective") and any charting or report you receive; follow that with your "objective" findings; then what you do is treatment.