Documentation

[travis23]

Hello everyone, I'm sure this topic has been a thread before but as a new EMT I'm curious on how everyone does there documentation and mainly how they get and write their narratives.

Any advice is apperciated

 

[DesertMedic66]

It seems most EMTs and Medics use the SOAP method or some variation of it.

 

[travis23]

SOAP??

Proceed?

 

[DesertMedic66]

Subjective (what the patient tells you)
Objective (what you see/found)
Assessment (what and how you assessed the patient and findings)
Plan (how you treated the patient).

 

[Akulahawk]

We're all different because we all have different forms to fill out. Some are little more than a blank sheet and we use the SOAP or CHARTED method. Sometimes we do a narrative for things that don't "fit" elsewhere, or we chart our physical exam findings by exception and what's considered "normal" is predetermined. There's just a LOT of variation because of those forms. I generally develop a boilerplate from which I plug in the relevant stuff, and that boilerplate is built from the specific form I'm using. This way I don't have to think about how to start the narrative, I already know. I just (quite literally) have to fill in the blanks and go from there.

Unfortunately, it's all in my head and it's form-specific, so I can't easily transcribe how I write my own reports here. Sorry.

 

[FLdoc2011]

Generally the subjective portion is just that, the "subjective" findings and thus things the patient/family/staff/ bystanders tell you.

Objective is what you objectively see/observe, so vital signs, physical exam, etc...

 

[Akulahawk]

Subjective (what you saw)
Objective (what the patient tells you)
Assessment (what and how you assessed the patient and findings)
Plan (how you treated the patient).

A little bit off...

S-Subjective (anything anyone tells you, including the patient)
O-Objective (your physical findings. Anything that's measurable and repeatable)
A-Assessment - based on the above, what you think is wrong
P-Plan - your plan of care that addresses those things that are an issue...
and I usually add (when doing SOAP notes)
I - Interventions - what I did specifically
E - Evaluation - how the interventions are working (or not)
R - Reassessment - based on above, what's changed, is a new plan needed, and basically re-enters the process at "assessment" above.

 

[DesertMedic66]

A little bit off...

S-Subjective (anything anyone tells you, including the patient)
O-Objective (your physical findings. Anything that's measurable and repeatable)
A-Assessment - based on the above, what you think is wrong
P-Plan - your plan of care that addresses those things that are an issue...
and I usually add (when doing SOAP notes)
I - Interventions - what I did specifically
E - Evaluation - how the interventions are working (or not)
R - Reassessment - based on above, what's changed, is a new plan needed, and basically re-enters the process at "assessment" above.

Yeah I know. I fixed it after I read my post.

 

[travis23]

Thanks guys this is helpful so far

My forms are pretty basic, narrative is my main concern

 

[Brandon O]

I like a chronological narrative myself, with some flexibility to group things if timeline isn't critical. It's funny, but SOAP, CHART, and a chronological format often end up looking pretty similar. We were dispatched here, here's the backstory we heard, this is what we saw and found, so we did this and brought them there.

There are some examples of how I approach the narrative here. However you handle it, and no matter what other fields your paperwork gives you, the point is to:

1. Present a coherent story
2. Mention anything not mentioned elsewhere, especially if significant
3. Look professional
4. Be thorough enough that readers will assume anything you DON'T mention DIDN'T happen
5. Cover your butt
6. If necessary, explain the reasoning behind your care

 

[Akulahawk]

I forgot to mention that sometimes I'll write an abbreviated H&P style note. Why abbreviated instead of the full-blown H&P? Simple. Time. How much is it abbreviated? Well, compared to an actual H&P, it's very abbreviated, but it gets the point across quickly.

I've also been known to use (and teach for simplicity's sake) the chronological format. It's probably the easiest to teach a new person. As that method begins to be mastered, it's then relatively easy to tweak that into one of the other charting methods.

 

[travis23]

Chronological seems to be the simplest way to document the call. I just need practice is all

 

[adamjh3]

It really depends on who I'm working for. The ambo gig is pretty big on ICHART, which I don't particularly like. Doing event work I tend to do a chronological narrative with a whole bunch of pertinent negatives that sometimes ends up looking a bit like SOAP.

Pt. Is a 16yo M who ambulated to aid station with steady gait while holding hand over R eye. Pt is A&Ox4, describes being struck below right eye with another players elbow. Denies LOC, -dizziness, -n/v, -nystagmus, -subconjunctival hemorrhage, - visual distubances. Ecchymosis and minor swelling noted in lateral periorbital region of R eye. Applied ice to affected area, advised pts father of s/s of TBI, eye injury advised to seek f/u if s/s develop. Pt released to father at xxxx.

 

[NJEMT95]

My reports are generally chronological:

"Unit # arrive on scene to find pt [supine/seated/walking toward rig]. Pt c/o [main symptoms]. Pt assessed [vitals/NOI/MOI & related details]. [Immediate on scene treatment] [Movement to rig] [Treatment & condition during transport] [Arrival at XXY facility].