Documentation

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AGill01

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One of my weaknesses as an EMT is my documentation. What do some of you use to remember what needs to be documented so you know you have covered everything in your narrative?
 
I know a lot of people use SOAP, CHART, or some other method. I prefer to do a chronological narrative. Some agencies will want you to use a specific format, others do not.

Practice is the best way to improve your narratives. I always tell people to read as many reports written by other people as you can. It will give you a chance to see different writing styles. Then, even if you don't tech the run, write a narrative for it. It is just that much more practice.

Another helpful thing is to find a format that you like, and stick with it. That way, even though the details may vary from one report to the next, each one is essentially the same.
 
Does your service not have a standard for documentation?

Most ambulance companies or EMS agencies have a standard that they prefer to be followed. Your field training officer or supervisor should be able to provide you with better information.
 
One of the companies I work for does. But I always seem to forget info. Ie. Lung sounds, any deformities, the patient's mental status. Why the patient had to be transported by ambulance. Just stuff like that.
 
I will admit documenting is not one of my strong points either but I usually begin with how the patient was found, their mental status and chief complaint. General impressions such as ABCs, LOC and vital signs assessed and WNL or whatever the case is. Then say the chief is CP I will document OPQRS, followed by pertinent negatives. Next I will list any interventions, how the patient was moved to gurney, how they were transported, their condition throughout transport and upon arrival to the ED followed up by the transfer of care.

Hope that helps.
 
If you're having trouble by forgetting to include pertinent items, make a list of all the things that you should include in a narrative and laminate it. Keep it out on the desk next to you when you write your report. That way you can just check things off on the sheet as you include them in your report. After a week or two, writing your report with all of those items included will become second nature.
 
My company uses a proprietary epcr for our charts. As a result my narratives are pretty short and simple because everything is in a pull down menu.

The Narrative portion is in the SOAP format. Best piece of advice I can give you is don't worry about grammatical structure in the form of sentences.

The S or Subjective is always the longest because that is what I am told.
 
Experience. You'll learn what's relevant, what's not, and what will make someone smile when they read it.
 
"Nursing staff report was spirited, but inaccurate in regards to patient's identification, medical history, and present complaint."

"Patient spontaneously localized multiple sites on her abdomen, torso and arms that she claimed were the source of her leg pain."

"Patient refused IV access, "you don't look too good at it".
 
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Haha.

Now, the good stuff in documentation is a different story.

"The patient related that she had a history of seizures, immediately closed her eyes, became non vocal and displayed "seizure like activity" for approximately 30 seconds. Following the "seizure", she opened her eyes and stated, "that was a bad one, right?"

Yahoo.
 
That has always been one of my weak points.
Follow and practice your company protocol. Use as many quotes in your subjective or miscellaneous sections as possible; if it doesn't fit but it's important, record it SOMEWHERE with date time and witnesses.
 
I wrote out a long reply then the intrawebs ate it. Sorry, not typing it again.

Practice makes perfect. Abbreviations are cool but can bite you in the ***. Be thorough but know what's pertinent and what you can leave out. For example the lady with toe pain doesn't need 8,000,000 pertinent negatives listed. "Denies any numbness/tingling in the effected extremity or any other associated symptoms or complaints" works just fine. Rather than "the pt denies any recent trauma, illness, medication changes, head/neck/back pain, dizziness, visual changes, weakness, chest pain/pressure, palpitations, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, numbness/tingling in the effected extremity or any other associated symptoms or complaints." See what I'm getting at?

Pick a format you like and stick to it. (SOAP or CHART or any variation of either). Eventually it will just be second nature. Ask your coworkers if you can read their charts. Pick things you like and things you don't like and develop your own style.

Don't make up reasons as to why an ambulance was required, that's fraud. Not advocating saying "they didn't need an ambulance" but DO NOT make up reasons. If your company is asking you to do that you should be looking for another job because that's not a place you want to be.

You can make your charts funny, but they must be professional. Example: "Upon arrival we find a xx year old male patient seated on the sidewalk against the building on the southwest corner of the above noted intersection dressed as a pirate yelling "Arrrrggg mateys hurry! He knifed me in my belly!" with mild external bleeding visible from his abdomen."

Funny to read and gives the reader a hilarious mental image but in the end that's exactly how it happened and if that call goes to court I will know exactly which one it was rather than one of the other random stab wounds to the abdomen I've run on this year.
 
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Right now as an EMT B I drive mostly, when we go on a call and have brought the pt to the hospital I go over in my head what I would say on a narrative then I try to read the medics to see how much I missed.
 
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