documenting a critical call

[emt seeking first job]

When you are on a critical call, I understand you would do the entire PCR (if your agency uses written ones) after the patient is in the car of the ER. However, are EMTs supposed to make notes when they take vitals in the field, or just memorize all interventions and observations until later ?

Are we supposed to jot them down on the form, just the vitals? A scratch pad? Or memorize them until able to write.

(yes, I should ask that a my vollie, but the most skilled person is not too receptive to questions, so I limit mine to him as "what do you want me to do now...?"

 

[medicRob]

When you are on a critical call, I understand you would do the entire PCR (if your agency uses written ones) after the patient is in the car of the ER. However, are EMTs supposed to make notes when they take vitals in the field, or just memorize all interventions and observations until later ?

Are we supposed to jot them down on the form, just the vitals? A scratch pad? Or memorize them until able to write.

(yes, I should ask that a my vollie, but the most skilled person is not too receptive to questions, so I limit mine to him as "what do you want me to do now...?"

I use an app called, "EMS Tracker" on my phone that allows me to keep track and plug in my data for when I am sitting in the ER finishing my narratives, etc. What did I do before the iPhone?

I wrote the info on my glove. We would also write on glove boxes if needed. If you have an iPhone, I recommend "EMS tracker" or "EMS Logger Pro". EMS Tracker is free, EMS Logger Pro is not.

 

[abckidsmom]

I use the code summary on the monitor. There's a feature that will time stamp iv's, drugs and "generic" on the timed printout of the vital signs. If the monitor is not getting the blood pressures, I jot them down in order with a quick time next to them.

 

[Aidey]

Scratch paper.

I got away from the whole glove thing after not thinking one day and throwing my gloves away....I had to get one of those elbow length OB pairs and go in after them.

 

[mgr22]

Documentation of all calls -- not just the "critical" ones -- is a must, but how much of that you get to do "real time" depends on the nature of the call and transport. Caring for your patient takes priority over writing about caring for your patient. Often that means you might have a chance to make some rough notes during the first 5-10 minutes of patient contact, but not a whole lot more. I used to stick a piece of tape on my thigh and use that as a notepad. Lately I've been using a small notebook instead. If you rode in a system with ePCRs, you'd probably have more formal procedures.

 

[mar7967]

When you are on a critical call, I understand you would do the entire PCR (if your agency uses written ones) after the patient is in the car of the ER. However, are EMTs supposed to make notes when they take vitals in the field, or just memorize all interventions and observations until later ?

Are we supposed to jot them down on the form, just the vitals? A scratch pad? Or memorize them until able to write.

(yes, I should ask that a my vollie, but the most skilled person is not too receptive to questions, so I limit mine to him as "what do you want me to do now...?"

What makes you think that "memorizing" is a good idea? you are bound to forget something, especially if you get another job before your first PCR is done...

My agency uses electronic PCRs, but I always have a notepad and on me that I use to write demographics, important parts of HPI, what I find in SAMPLE, and any vitals I take. And I use that when doing my chart after leaving the hospital. I usually don't touch the computer until after I am at the hosptial...critical call or not.

 

[Aidey]

I should also add that on a really critical call, especially those with a short transport, you may not have much to write down.

I've walked into the ER before with patients that have been shot/stabbed and had a name, b-day, and pulse and that is about it. If you pick up an unconscious patient off of the street the only info you may have on him is his ID. If the pt is critical enough you may never get past the A or B of ABC.

 

[medicRob]

Documentation of all calls -- not just the "critical" ones -- is a must, but how much of that you get to do "real time" depends on the nature of the call and transport. Caring for your patient takes priority over writing about caring for your patient. Often that means you might have a chance to make some rough notes during the first 5-10 minutes of patient contact, but not a whole lot more. I used to stick a piece of tape on my thigh and use that as a notepad. Lately I've been using a small notebook instead. If you rode in a system with ePCRs, you'd probably have more formal procedures.

I get the critical stuff at the scene. This is when I am doing my sample history (Drug allergies, etc), Chief Complaint, and anything I am going to need to know before I push a med or have to present them to the physician. My EMT-IV usually grabs me some vitals while I set up the IV tray if necessary, and I Log the times on EMS Tracker. When we get to the ER after presenting, I get the patient's license and fill out the nitty gritty (Address, etc) at the nurses station. In your average stable medical patient, I might fill out a little bit of my narrative on the way while doing my detailed assessment.

You are not going to finish your run report on scene, get that out of your head now. Just make sure to get known drug allergies, chief complaint, your vitals, etc and what you are going to say to the receiving doc or RN when you get to the ER and fill in the details of your narrative at the ER.

 

[emt seeking first job]

Documentation of all calls -- not just the "critical" ones -- is a must, but how much of that you get to do "real time" depends on the nature of the call and transport. Caring for your patient takes priority over writing about caring for your patient. Often that means you might have a chance to make some rough notes during the first 5-10 minutes of patient contact, but not a whole lot more. I used to stick a piece of tape on my thigh and use that as a notepad. Lately I've been using a small notebook instead. If you rode in a system with ePCRs, you'd probably have more formal procedures.

Of course, all calls get documented.

However, a stable patient, I have watched EMT's sit with a clip board and PCR writing down the information. Not wasting time, but able to make notes in a calm manner.

The tape on the thigh is useful suggestion.

 

[emt seeking first job]

thank you for the replies, all

My agency, a nyc vollie, uses written pcrs only.

An iphone is not in my budget for the foreseeable future.

I am just curious, in my past when I worked as a LEO, we were trained that scratch notes on scrap paper are a non-no, all notes must be in a memo book, which are saved for ever, write reports off notes in the memo book.

I knew an LEO, not in same agency as me, who made scrap notes on his hand...

I am curious if the issue of writing down notes ever comes up in court...

However, the individual EMT b/p is most likely OK if he or she did not violate some sort of written agency procedure on notes.

 

[emt seeking first job]

What makes you think that "memorizing" is a good idea? you are bound to forget something, especially if you get another job before your first PCR is done...

My agency uses electronic PCRs, but I always have a notepad and on me that I use to write demographics, important parts of HPI, what I find in SAMPLE, and any vitals I take. And I use that when doing my chart after leaving the hospital. I usually don't touch the computer until after I am at the hosptial...critical call or not.

I am not sure if all agencies have this luxury, but my vollie, by practice, will do the pcr's at the hospital, before they radio that they are available for the next job...

And in four weeks every job but one was buffed or we were flagged or came upon something.

The one phone call we got was a member of our service who was off duty and called in a MVA....

 

[wyoskibum]

EMS ain't Law Enforcement

I am just curious, in my past when I worked as a LEO, we were trained that scratch notes on scrap paper are a non-no, all notes must be in a memo book, which are saved for ever, write reports off notes in the memo book.

I am curious if the issue of writing down notes ever comes up in court...

However, the individual EMT b/p is most likely OK if he or she did not violate some sort of written agency procedure on notes.

The rules are different for EMS than LE. You can make notes that you use to create the formal, legal document (PCR). There isn't an issue unless you save the notes or if they have personal information and you didn't shred/destroy them properly.

 

[mar7967]

However, the individual EMT b/p is most likely OK if he or she did not violate some sort of written agency procedure on notes.

Varies by agency I am sure. There is probably someone out there who says you can't take notes however you want. You just need to make sure you properly dispose of your notes...anything with a patient name, address, etc, I make sure I shred it. It all gets copied into the PCR so there is no reason to keep it. If you do keep notes in a bound book, you need to make sure you dont lose it or misplace it or anything, since it will have sensitive patient information in it.

I am not sure if all agencies have this luxury, but my vollie, by practice, will do the pcr's at the hospital, before they radio that they are available for the next job...

I definitely do not have that luxury. We get to the hospital, drop our patient, and get back in service. We work on PCRs enroute (some people), while waiting for triage, on the way back to our base, and then when we get back. We handle about 5500 calls a year with 3 day crews and 2 overnight...it is not uncommon to get another call before finishing a prior PCR. And on top of that, we are supposed to get them in within 3 hours of arriving at the hospital...not always possible.

 

[feldy]

i would think that most hospitals now give out face sheets (from pt registration) that has all their info on it. Obvious if you are picking up an unconcious pt w/o family present then you wont have any info.

i use a small note pad b/c it is easy. you are not gonna remeber evey medication the pt is on (espeically if they are older and take 10+ meds).

 

[medicRob]

i would think that most hospitals now give out face sheets (from pt registration) that has all their info on it. Obvious if you are picking up an unconcious pt w/o family present then you wont have any info.

i use a small note pad b/c it is easy. you are not gonna remeber evey medication the pt is on (espeically if they are older and take 10+ meds).

We are on Tough books at my service now. However, I still find it easier to shake my iPhone to mark the time and enter my vitals. As long as I don't enter the patient's name, address, etc into my device--I am good. My screen ends up looking like this:

 

[emt seeking first job]

We are on Tough books at my service now. However, I still find it easier to shake my iPhone to mark the time and enter my vitals. As long as I don't enter the patient's name, address, etc into my device--I am good. My screen ends up looking like this:

That looks very useful.

If you are really scrambling to ventilate, compress, control bleeding, do you ever accidentally drop the iphone, or if both hands are occupied, say controlling bleeding, then I am guessing you must wait?

 

[medicRob]

That looks very useful.

If you are really scrambling to ventilate, compress, control bleeding, do you ever accidentally drop the iphone, or if both hands are occupied, say controlling bleeding, then I am guessing you must wait?

All I have to do is shake the phone or push a button as it sits by the life pak. However, if my patient is truly critical I am not worried about all that anyways. I am going to be more worried about assessing those vitals q5 than I am about getting the time down to the second on my run report. If your patient is that critical, there is no time to stay and play, it is time to get up and go--worry about your times when you get him to the ER. You can radio dispatch and ask them for your Run #, dispatch time, etc. Trauma pt are monitored q5, so if I have 3 sets of vitals, I am going to write the first one down for about 3 minutes after my arrival on the scene, mark the second one 5-7 minutes later, and the third 5-7 minutes after that.

 

[emt seeking first job]

All I have to do is shake the phone or push a button as it sits by the life pak. However, if my patient is truly critical I am not worried about all that anyways. I am going to be more worried about assessing those vitals q5 than I am about getting the time down to the second on my run report. If your patient is that critical, there is no time to stay and play, it is time to get up and go--worry about your times when you get him to the ER. You can radio dispatch and ask them for your Run #, dispatch time, etc. Trauma pt are monitored q5, so if I have 3 sets of vitals, I am going to write the first one down for about 3 minutes after my arrival on the scene, mark the second one 5-7 minutes later, and the third 5-7 minutes after that.

Is the phone in a case which exposes the face of it ?

I am still working out where to keep all my equipment, and I am a minimalist. I am forcing myself to keep everything in the same pants pocket.

This job is harder than being an LEO.

 

[medicRob]

Is the phone in a case which exposes the face of it ?

I am still working out where to keep all my equipment, and I am a minimalist. I am forcing myself to keep everything in the same pants pocket.

This job is harder than being an LEO.

I have insurance and the iPhone is made of hardened glass and stainless steel. Plus, I have the insurance.

see here:
http://www.apple.com/iphone/design/

 

[emt seeking first job]

I have insurance and the iPhone is made of hardened glass and stainless steel. Plus, I have the insurance.

see here:
http://www.apple.com/iphone/design/

So your iphone is not in either hand, you can just reach to tap or shake it?

Does it give some sort of audibile tone so you can tell it was activated without looking at it?