emsCharts
- Thread starter NJEMT95
- Start date
Bullets
Forum Knucklehead
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There is no section for a narrative.
What would go in a narrative is broken up through multiple pages and fields. When switching from paper to EMS charts you must change the way you think about documenting. If you simply enter demographics, EMScharts will generate a chart for a healthy normal individual with no problems, you then include the abnormalities. In the past you most likely charted by exclusion, ie "patient had no LOC, no DCAPBTLS, no airway issues, ect"
In EMScharts you add if there was issues
Page 2
Chief complaint is a character restricted field, only a few words, so you'd put something like "Pain" or "altered mentation" or "change in responiveness"
Seconday Complaint is the same, so like "weakness"
HPI is everything that happened prior to your arrival, so for a call for tachycardia "Pt was lying in bed at our arrival. PD Officer had provided O2 via NRB. Pt. complained of severe headache, racing heart, and general weakness. She had been treated at hospital 5 days previous for these symptoms. The medications she has been taking for 5 days have not diminished the symptoms. "
page 3,4,5 are your findings for the physical assessment and are pretty self explanatory
page 8, the activity log is what you did to the patient, so it could be as simple as "Patient moved to cot, secured x3, placed in ambulance" if you administer medication (oxygen is a medication) splint, SMR you use the drop down menu and fill in the fields
Any questions about EMScharts, feel free to PM me
What would go in a narrative is broken up through multiple pages and fields. When switching from paper to EMS charts you must change the way you think about documenting. If you simply enter demographics, EMScharts will generate a chart for a healthy normal individual with no problems, you then include the abnormalities. In the past you most likely charted by exclusion, ie "patient had no LOC, no DCAPBTLS, no airway issues, ect"
In EMScharts you add if there was issues
Page 2
Chief complaint is a character restricted field, only a few words, so you'd put something like "Pain" or "altered mentation" or "change in responiveness"
Seconday Complaint is the same, so like "weakness"
HPI is everything that happened prior to your arrival, so for a call for tachycardia "Pt was lying in bed at our arrival. PD Officer had provided O2 via NRB. Pt. complained of severe headache, racing heart, and general weakness. She had been treated at hospital 5 days previous for these symptoms. The medications she has been taking for 5 days have not diminished the symptoms. "
page 3,4,5 are your findings for the physical assessment and are pretty self explanatory
page 8, the activity log is what you did to the patient, so it could be as simple as "Patient moved to cot, secured x3, placed in ambulance" if you administer medication (oxygen is a medication) splint, SMR you use the drop down menu and fill in the fields
Any questions about EMScharts, feel free to PM me
DrParasite
The fire extinguisher is not just for show
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you don't. EMS charts is designed (rightfully so) so you shouldn't need a narrative.
Pages 3 to 7 are everything that happened before you made patient contact, including the patient's condition and your findings upon assessment
Page 8 is a flow chart, documenting what interventions you did, with it broken down by the time you did it.
You shouldn't need a narrative, unless there is something super special about the call (and I haven't found many in my career that warrant a "narrative", despite partners that try to put one somewhere)
Pages 3 to 7 are everything that happened before you made patient contact, including the patient's condition and your findings upon assessment
Page 8 is a flow chart, documenting what interventions you did, with it broken down by the time you did it.
You shouldn't need a narrative, unless there is something super special about the call (and I haven't found many in my career that warrant a "narrative", despite partners that try to put one somewhere)
Ace 227
Forum Lieutenant
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Basically what everyone else has been saying. The closest thing to a narrative would be the CC/HPI section and the activity log.
When I write my activity log I usually follow a similar format.
-On scene
-At pt. This is where I'll do a narrative of sorts. usually "At pt, 56 yof sitting upright on the edge of her bed, A&Ox4 and dressed appropriately. She states that she has "felt like crap" since ~14:00 yesterday and that now she is having difficulty breathing and chest pain. She has visible dyspnea and is clutching her chest. etc...
-Enroute. This is where I will continue my narrative from "at pt.". I will write something like "Enroute to Local Hospital ED. Pt vitals and PMHX assessed. She denies headache, nausea/vomiting, or pain and states that her chest feels "tight". *I will also use the "add actions" button here for any interventions
-Repeat vitals as necessary
-Notify hospital via Add Action
-Arrive at ED.
-I conclude with transfer of care which will complete my narrative. "Pt taken to Rm 11 of ED and transferred to bed via 2 person sheet drag. EMT 123 witnesses pt sign Consent to Transport form, report is given to receiving staff, and care is transferred."
Every service has a different way they want it done depending on how they do billing, etc. My fire department is much more strict than my private company.
Hope this helped!
When I write my activity log I usually follow a similar format.
-On scene
-At pt. This is where I'll do a narrative of sorts. usually "At pt, 56 yof sitting upright on the edge of her bed, A&Ox4 and dressed appropriately. She states that she has "felt like crap" since ~14:00 yesterday and that now she is having difficulty breathing and chest pain. She has visible dyspnea and is clutching her chest. etc...
-Enroute. This is where I will continue my narrative from "at pt.". I will write something like "Enroute to Local Hospital ED. Pt vitals and PMHX assessed. She denies headache, nausea/vomiting, or pain and states that her chest feels "tight". *I will also use the "add actions" button here for any interventions
-Repeat vitals as necessary
-Notify hospital via Add Action
-Arrive at ED.
-I conclude with transfer of care which will complete my narrative. "Pt taken to Rm 11 of ED and transferred to bed via 2 person sheet drag. EMT 123 witnesses pt sign Consent to Transport form, report is given to receiving staff, and care is transferred."
Every service has a different way they want it done depending on how they do billing, etc. My fire department is much more strict than my private company.
Hope this helped!