Help me clean up this narrative

[adamjh3]

Yesterday I ran my first actual call, as in not a "routine" hospital discharge, dialysis transfer, SNF to ER for abnormal labs etc.

First, I want to say this call was handled absolutely wrong from the person who called our dispatch all the way up.

Call came out as a transfer from a boarding care facility to a local hospital with no ED. We had no chief complaint going into the call, and thus had no idea what we were walking in to (you really never do, but I digress).

I'll now go into what I wrote down for my narrative, and welcome the opportunity for the wise folks on here to tear it to shreds. I want to be criticised on everything from documentation to how we handled the call.

Narrative
Age: 27 Gender: M Status: Mild
(Cx) Head Trauma (Hx) Pt. Dx schizophrenia, no similar events in history. (Ax) Pt found standing in hallway outside of his room, ambulated to gurney. Pt A&Ox3, VS stable and within normal limits, Pt. denies pain, nausea, vomitting in last 24hrs. Hematoma approx. 1" in size present on forehead directly midline with a small abrasion covering hematoma. Dried blood present inferior to wound extending downward to browline. Pt. states wounds were self-inflicted from repeatedly striking his head against the wall several times x 2 days. Approx 5 minutes into Tx, patient began striking his head against the cabinet in the ambulance, Pt. struck his head approx 3-4 times. C2 provided manual stabilization of Pt's head to prevent further injury. No obvious injuries were caused at this time. Pt. was told if he continued this behavior he would be placed in 4Pt restraints. Pt. became compliant. (Rx) Cleansed wound with NS and guaze, wound dressed, and wrapped cold-compress placed over wound x approx. 4 minutes. (Tx) To (redacted) Hospital, in pos. of comfort w/o further incident.



Alrighty, tear this to pieces.

Thanks,
-Adam

 

[JPINFV]

Something to keep in mind, a lot of narritive writing comes down to personal style. What's important is that the proper components are there in a logical format then how the format was actually written.

Tenderness?
Any other neuro deficits?
Any other medical history besides schizophrenia?
Did you talk to the staff at the board and care? What did they say?
I always include a boilerplate comment that the "patient was transported with seatbelts and siderails"
Even though my level of suspecion of a closed head injury or spinal injury would be low, what was the pupils and neck exam (including specifying no pain or tenderness specifically to this region even though the patient globally denied pain)?

As a side note, SNF-> ER for abnormal labs can be a very critical call. The question is, of course, what labs, and what values?

Any damage to the wall?

 

[adamjh3]

Something to keep in mind, a lot of narritive writing comes down to personal style. What's important is that the proper components are there in a logical format then how the format was actually written.

Tenderness?
Any other neuro deficits?
Any other medical history besides schizophrenia?
Did you talk to the staff at the board and care? What did they say?
I always include a boilerplate comment that the "patient was transported with seatbelts and siderails"
Even though my level of suspecion of a closed head injury or spinal injury would be low, what was the pupils and neck exam (including specifying no pain or tenderness specifically to this region even though the patient globally denied pain)?

As a side note, SNF-> ER for abnormal labs can be a very critical call. The question is, of course, what labs, and what values?

Any damage to the wall?

No tenderness. No neuro deficits

I failed to mention, after the narrative there are seperate boxes for Medical history, allergies, meds, and then boxes for GCS, pupil exam, cap refill, lung sounds, pain and tenderness exam, skin signs and then another box for intubated patients.

I tend to only remark on something in my narrative if it's marked as abnormal in any of the boxes. Say his eyes were not PERL, left at 6, right at 4, I would comment on that in my narrative. But if it is not abnormal I don't usually write it in my narrative. If he had point tenderness in his neck, I comment in my narrative. Is this improper?

For history, I usually only state pertinent history in the narrative. This patient stated he was hitting his head on the wall because he was being told to by "the voices." On this call though, pt. had no other medical Hx.

I did talk to the staff at the board and care, they stated that the patient had been acting normal other than outbursts approximately twice a day over the past two days in which he would strike his head against the wall several times. They suggested he may need a med adjustment.

I like the "Seatbelts and side rails" line, I may start adding that to my narrative.

I probably should have remarked that he stated the wound did not hurt. Noted.

No damage to the wall.

And yes, abnormal labs can be something very bad. I meant it as this is the first call where I have done more than pick-up, assess, drop off, with no patient care other than transporting in a posistion of comfort.

 

[JPINFV]

While I do agree that I generally leave off things documented elsewhere unless pertinant, however with a head trauma I would consider those pertinant (neuro assessment and neck exam). If I'm not doing something 100% by the book (book answer: ZOMG TRAUMA, C-SPINE C-SPINE, C-SPINE. I'm also not saying that this patient, based on how you're presenting the case, needed spinal immobilization, even if you were going to an emergency department), I want to sell it. It's much easier to defend not doing X if I can point to the narritive where I explicitly spelled out, "patient denies neck pain and tenderness, pupils PERRLA, PMS [pulse/motor/sensation] intact x 4" versus, "it's documented elsewhere."

If the staff reports something, document that if not documented elsewhere. "Staff reports..." That's also how I document BGL levels on SNF patients going to the emergency room. Ask the CNA, LVN, or RN to get an updated BGL and then document, "LVN reports a BGL of ____ at ___"

 

[adamjh3]

JP, thank you very much for your thoughts, learning has occurred.

 

[DrankTheKoolaid]

re

Incident History - Blah Blah was dispatched to the report of a patient transfer from Blah Blah to Blah blah ER. Arrived on scene and ( received or did not receive ) report from facility staff who states patient with no prior history of violent outbursts. Patient found ambulating in hallway and ambulated to the gurney upon noticing our presence without assistance. Patient states understands being transport to the ED for further evaluation. Patient then from facility to ambulance without incident and without belongings.
C/C None ( Abnormal laboratory values ) Patient denies C/P, SOB, N/V or loss of consciousness PX - CAOX4, Skin normal warm and dry, PERRLA, HENT with noted hematoma mid line on forehead with patient stating this is from his repeated striking of his head on the walls of the facility with bleeding self limited, Neck supple and non tender to palpation of the cervical thoracic or lumbar spines, Chest bilateral equal rise and fall with clear and equal lung sounds all fields, Abd soft non tender to palpation with no noted masses, Pelvis stable with patient not noted to be incontinent of stool or urine with patient denying polyuria dysuria or hematuria, Distal CSM intact x 4. TX - Patient placed position of comfort on the gurney on semi fowler's position, O2 applied 3 L/min via NC, VS as noted, CM showing Blah Blah If ALS. WHile in transit patient noted to become increasingly agitated and began to repeatedly strike head against nearest shelf. After advising patient of needing to restrain him if the same activity and behavior continued was able to talk patient down verbally, with no further incidence. Patient hematoma on forehead noted actively bleeding. Pressure applied with all bleeding stopped, Wound then cleaned and dressed with a DSD and secured. Radio report to receiving facility with no questions. Remainder of transport was uneventful with no other patient complaints or changes.
Upon arrival at Blah Blah patient with no belongings was then transferred from gurney to ED bed C without incident. Full report then given to ED staff with no questions. Blah Blah available. P2****

 

[JPINFV]

^
Corky, are you suggesting administering supplemental oxygen to this patient or was that just an example for the narritive?

 

[DrankTheKoolaid]

re

No this was just purely an example on how to write a narrative, though one can argue that his altered mental status may have been caused by hypoxia since O2 saturation is not noted. And yes i noted his DX

Also there is no such thing as (within normal limit's ). This term should never ever ever be used in a chart. What is one persons baseline is not anothers

 

[adamjh3]

No this was just purely an example on how to write a narrative, though one can argue that his altered mental status may have been caused by hypoxia since O2 saturation is not noted. And yes i noted his DX

Also there is no such thing as (within normal limit's ). This term should never ever ever be used in a chart. What is one persons baseline is not anothers

I understand your reasoning for not writing "within normal limits."

What about "within normal limits per facility staff?"

 

[JPINFV]

Also there is no such thing as (within normal limit's ).

There really isn't anything wrong with acknowledging that something is within normal limits (or reference values if you will). What's important is to understand that just because something is WNL doesn't mean a provider can become complacent over it. Even normal values can be decidedly abnormal under the right circumstances.

 

[mcdonl]

Just learning too....

I am only a few month's into it but I have done 150 or so calls under three different QA/QI guys. We have a new QA/QI guy so I am learning again. He said "When you have been doing this for 5 years and have not lost your license, you can do any kind of narrative you want. Until then, your doing SOAP notes...."

Also, he provided us with "cheat sheets" for assessments that go hand - in - hand with the SOAP format. I hated it, and him at first but now I just hate him. I actually like the format and the cheat sheets. PM me if you want, and I will send you one of each... the assessment card and the associated notes card...

O: demographics, CC, pertinent hx/meds and bystander reports (Short and sweet) Should tell the reader why you were called and what you were told.

S: Your observations pertinent to the condition (I am being taught that your assessment (A at the end should be consistent with your findings, and treatments for proper billing.

Then on EVERY patient we do LOC, SKIN, HEENT, NECK, CHEST, ABDOM, NEURO, CARDIAC, CSM's, SCENE, ODORS.

We put meds, vitals, allergies as listed (Meaning it is elsewhere in the report...although depending on the call if it is relevant we will put it in the narrative)

P: My QA/QI guy makes me list and number everything we do. And, it had better be consistent with the assessment and the findings or we get dinged. We are on call # 385 right now for the year, so we average about 800-900 calls and they all get QA/QI.

Finally the A: It needs what and why you transported or recommended transport. such as A: CHEST PAIN (R/O MI)

I hope this helps, and good luck!!

 

[MrBrown]

I would call your reports far too wordy and detailed however it may be appropriate given the complex mediciolegal framework you work under.

Brown would write something like this ....

Hx schizophrenia

O/A conscious and alert, standing in hallway outside room, well perfused, walked to gurney

O/E small 1in haemotoma on forehead, pt stated from striking head on wall

Treatment none

Transport, pt began to strike head against side wall of vehicle, complied when asked to stop.

We record vital signs seperately on the PRF

 

[mar7967]

In my narratives, I first put what I was dispatched to and any dispatch information. As we all know, that doesn't usually match up with the actual details of the call, but I put it in there anyway. I then put what I found on scene, pt's chief complaint, and a few sentences on what led up to it, how it happened, etc. I then put all of my pertinent positives or negatives (Loss of conscious, SOB, N/V/D, chest pain, head/neck/back pain, etc). We have separate sections for Pt's allergies, Hx, meds, etc. We have a separate section that I list the treatments in. In the narrative, I just put what I discovered in the first few minutes of the call.

 

[JPINFV]

O: demographics, CC, pertinent hx/meds and bystander reports (Short and sweet) Should tell the reader why you were called and what you were told.

S: Your observations pertinent to the condition (I am being taught that your assessment (A at the end should be consistent with your findings, and treatments for proper billing.

Then on EVERY patient we do LOC, SKIN, HEENT, NECK, CHEST, ABDOM, NEURO, CARDIAC, CSM's, SCENE, ODORS.

We put meds, vitals, allergies as listed (Meaning it is elsewhere in the report...although depending on the call if it is relevant we will put it in the narrative)

P: My QA/QI guy makes me list and number everything we do. And, it had better be consistent with the assessment and the findings or we get dinged. We are on call # 385 right now for the year, so we average about 800-900 calls and they all get QA/QI.

Finally the A: It needs what and why you transported or recommended transport. such as A: CHEST PAIN (R/O MI)

I hope this helps, and good luck!!

:Grumble grumble grumble:

The objective includes the review of systems, which is everything the patient tells you (for example, does the patient complain of or deny nausea, vomiting, diarrhea, chest pain, etc) and the history of present illness which is where you put your OPQRST.

Proper SOAP note formating:
S:

• History of present illness
• Allergies
• Past Medical History
• Past Surgical History
• Medications
• Social History
• Review of Systems:
  1. General
  2. HEENT
  3. Neck
  4. CV
  5. Resp
  6. ABD
  7. GU
  8. Muscular-skeletal
  9. Skin
  10. Psych
  11. Neuro

Objective (physical exam) is similarly divided into a list like ROS, however starting with vital signs and ending with lab results (if applicable).

Assessment: Working/differential diagnosises

Plan: Treatment.


Personally, if I was working on an ambulance today, I'd add a Prearrival section ([dispatched code 2/3 for [dispatch C/C], and abnormalities during response [Delayed on response at an at-grade railway crossing]) and a Changed [delta] section documenting how the patient responds to treatment.

 

[adamjh3]

I would call your reports far too wordy and detailed however it may be appropriate given the complex mediciolegal framework you work under.

Brown would write something like this ....

[Berevity]

Brown, you bring up an interesting point. JP, and others, do you feel everything we've put in the narrative is necessery?

I'm asking out of pure ignorance. I've been told the more detailed the better. Write like every single call is going to court. How do you folks feel about this?

 

[mcdonl]

Brown, you bring up an interesting point. JP, and others, do you feel everything we've put in the narrative is necessery?

I'm asking out of pure ignorance. I've been told the more detailed the better. Write like every single call is going to court. How do you folks feel about this?

I put in everything I feel is important AND everything our QA/QI guy wants in the report.

 

[JPINFV]

I would call your reports far too wordy and detailed however it may be appropriate given the complex mediciolegal framework you work under.

Brown would write something like this ....

Hx schizophrenia

O/A conscious and alert, standing in hallway outside room, well perfused, walked to gurney

O/E small 1in haemotoma on forehead, pt stated from striking head on wall

Treatment none

Transport, pt began to strike head against side wall of vehicle, complied when asked to stop.

We record vital signs seperately on the PRF

You go to your PMD for a regular check up. Do you expect:

A: Nothing found, schedule next check up in 6-12 months.

B: Documentation of everything checked and asked about, even if the finding was normal or condition (e.g. pain, nausea, vomiting, diarrhea) denied.

 

[Hellsbells]

Call came out as a transfer from a boarding care facility to a local hospital with no ED.

If you feel this pt needs to go to a facility with an ER dept, you should take him there.

What about "within normal limits per facility staff?"

Thats ok, but why bother putting it in at all? The vitals should be written on the run sheet, so unless they are unusual, then whoever reads the report can simply look at the recorded vitals.

 

[adamjh3]

If you feel this pt needs to go to a facility with an ER dept, you should take him there.

Patient was legally responsible for himself, and declined to go to our nearest facility with an ER, and rather opted to go to one of the local hospitals with a mental health unit.

Thats ok, but why bother putting it in at all? The vitals should be written on the run sheet, so unless they are unusual, then whoever reads the report can simply look at the recorded vitals.

I've put that in because I've had patient's with vitals that look odd, but are completely normal for them. Say a BP of 70/40; I was stunned when I saw that, but the staff at that patient's facility said that was normal for her.