HELP...Run Report Narratives

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EMT_TIFFANY

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Need advice on writing narratives for run reports. We didn't practice it enough in basic and I don't run anywhere. I'm hopelessly lost at this time. Can anyone direct me in the path of how to write an organized and complete narrative. Any help would be GREAT :wacko:
 
Tell a story about what happend on the call. You always want to make sure that if someone who was not there could follow your call and know what you are doing.
 
ICHART

Incident
Chief Complaint
History
Assessment
Rx
Transport
 
I always start my reports, "Called for XX year old pt with XX complaint" Arrived on scene to find: (initial condition of pt, any pertinent info on location (lying on floor, sitting in chair, hanging off roof, etc.) then initial vitals, treatment on scene, method of transfer to ambulance, additional findings during assessment, condition and treatment during transport and anything else that might be helpful to know or explain an oddity in the fill in boxes above on the PCR.
 
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W1IM said:
I always start my reports, "Called for XX year old pt with XX complaint" Arrived on scene to find: (initial condition of pt, any pertinent info on location (lying on floor, sitting in chair, hanging off roof, etc.) then initial vitals, treatment on scene, method of transfer to ambulance, additional findings during assessment, condition and treatment during transport and anything else that might be helpful to know or explain an oddity in the fill in boxes above on the PCR.
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+1


And Document...Document...Document.... If you don't document it then it didn't happen. Just to CYA if it ever gets pulled into court. ;)
 
My run reports resemble the following:

"Pt found sitting upright c/o weakness. Patient states "I've just felt sick the last few days and have gotten weaker. Today I couldn't get out of bed" also states "I can't keep anything down". Intial vital signs obtained as listed above, - soa, - CP, +N/V x3 days. - loc, a/ox4. Placed on O2 @ 4lpm via NC. Patient moved to ambulance with assistance to stretcher, -> C-X to Hospital. Enroute: V/S monitored as attached (Note I attach a record of my vitals), O2 maintained @ 4lpm, aquired chemstick, physical exam performed with initial findings as above (Note Initial findings are listed above). Upon Arrival to *hospital* - Changes in condition. Patient triaged, xx minutes, care transferred to ER Nursing staff. END"

Generally. IT changes of course but that's been a common narrative as late. I usually write 2 page reports as we have not gone to ePCR yet.
 
Something like this works well for me:

-Impression
-Assessment including pertinant negatives
-Treatment and response

For example this is roughly a job I went to on Thursday

"Located 65yof sitting in lounge chair in company of daughter. Pt awake and alert to crew presence w/o signs of obvious injury or illness. Daughter states patient seen by AOs previous evening (PRF No. XXX) cc N/V but not transported. Pt states she felt unwell since Tuesday now feels dehydrated w/ increased urination, hx IDDM for which she takes insulin but has taken since 7am Tuesday and latest BGL 10am this morning read high. BGL obtained at 11.7. 18ga. IV L forearm > 1L NS TKO."

Note that we record vital signs seperately in another part of our form.
 
My suggestion is to not be lazy with your run report. Right down what you find and what you did. If you did not do it or do not write it down, IT DID NOT HAPPEN! If you are taken to court and you say "oh well I did that, I just forgot to write it down" you will get eaten alive.

I usually don't record my exam findings IN the narrative just because we have a page for 'initial physical exam' which lists all the normal things you're looking for. ABC's, extremeties, chest, abdomen, etc. I will write exam findings in the run report if I repeat them and they change,or the patients condition changes: for example something like below.

"Pt found lying supine c/o H/A. Pt states "this is the worst headache I've ever had", reports no Hx of migrages, stroke/tia, seizures. Pt pale, reports H/A @ 10/10 pain and along L temporal region, does not migrate. Pt states H/A since approx 11am today (11/17), has taken 1gm OTC Tylenol s relief. Initial vitals taken as recorded above, O2 placed on pt @ 4lpm via NC, moved to ambulance via stretcher. -> C-1 *hospital*. Enroute V/S monitored as attached (attach to run), O2 maintained @ 4lpm NC, chemstick and physical exam c findings above. Approx 5 minutes from *hospital* pt states "I don't feel right", facial droop visible. stroke scale performed with pronounced weakness on R side, + Facial droop, + Arm Drift, + Motor Function Loss, + Speech Impairment. -> C-3 (time), *hospital* called, report given, request for stroke team approved. Arrived to *hospital* c no further changes, bypass triage to stroke team. Care transferred to stroke team s incident."

The above is an example of a stroke I had recently with some changes and some of it I don't remember so I made parts up :P
 
Dominion said:
My suggestion is to not be lazy with your run report. Right down what you find and what you did. If you did not do it or do not write it down, IT DID NOT HAPPEN! If you are taken to court and you say "oh well I did that, I just forgot to write it down" you will get eaten alive.
Click to expand...

To add on to this, if you didn't do something for a reason (i.e. short transport time or other factors) document the reason.
 
I personally am a fan of the CHART method of documentation. For one I find that it is easier than SOAP, and also because the majority of reports done by doctors I've read roughly follow CHART. I think providing a narrative to the hospital in a format the MDs and RNs are familiar with makes it easier for everyone.

CHART is CC, HX, Assessment, Rendered care, and Transport.

Here is an example of a CHART narrative. In real life the computer program we use has a seperate place for past history, meds, allergies, interventions and vitals so none of those make it into the narrative unless they are pertinent to the situation. For example, the before and after blood glucose numbers in a hypoglycemic patient, or before and after BPs in a Pt given a fluid bolus.

CC: R wrist pain

HX: The patient is a 17 year old male being transported from a skate part this evening. History is obtained from the patient and bystanders on scene. Pt state that while executing a trick on his skateboard he lost his balance and fell forward onto the concrete surgace with his arms outstretched. When he landed on his outstreched hands he felt and heard a "snap" in his R wrist, and he also had an acute onset of pain in the extremity. A bystander obtained ice and placed it on the pts wrist while they waited for EMS to arrive on scene.

The pt states the pain is a 6/10. Moving or touching the wrist exacerbates it, and holding it still reduces the pain. (Note, this isn't a complete OPQRST because quality, radiation, and time aren't really relevant in this situation).

The pt was wearing a helmet, and denies hitting his head or LOC. He was not wear wrist guards. His last oral intake was at 1200 today. He denies drinking alcohol or abusing medications or illegal drugs.

The pt has a past medical history of ADD, for which he takes Adderall. He has NKDA.

Assessment:
General: Pt contacted lying on the ground. Pt is stable.
Neuro: GCS 15. No LOC
HEENT: Airway open. Eyes PERLA. No cyanosis noted around the mouth.
Neck/Back: Trachea midline. Pt denies neck or back pain. No DCAP-BTLS, TIC or step off noted on palpation of the spine.
Chest: Equal and bilateral chest rise and fall with inspiration and expiration. Lung sounds clear and equal in all fields.
Abd: SNT.
Extremities: CSM intact x4. The pts R wrist has a deformity on the lateral side when compared to his L wrist. There is swelling present and bruising along the lateral side. Cap refill in R hand is less than 3 seconds. Pt can move his fingers, but can not move his wrist without pain. Pt denies numbness or tingling in his fingers.

R: Assessment. Vital signs. Pts R wrist placed in a cardboard splint and splinted in position of comfort. Cold therapy applied to wrist. CSM rechecked every 10 minutes during transport.

T: Pt contacted his mother via cell phone prior to EMS arrival. She instructed the pt to go to Children's Hospital and she would meet him there. Pt ambulated to gurney. Seat belts applied to pt and gurney was moved to the ambulance. Pt was transported to Children's Hospital at parent's request and transferred to room 10. Care was turned over to the nursing staff there.
 
JPINFV said:
To add on to this, if you didn't do something for a reason (i.e. short transport time or other factors) document the reason.
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This is a big one for me, it's easy to remember why you did something, but it isn't easy to remember why you didn't do it. In my narratives I stick this under the treatment section. Say I have a patient with a port, I would write "Pt reports that he has a port in his right upper chest. Since pts vital signs were stable, peripheral IV access was deferred in favor of the pts port being accessed at the ER."
 
As a basic, you should not really have to document why you didn't do something ,unless it's related to a short time period or there are specific circumstances. For the most part you should be able to perform all of your skills on every patient. Generally the only time I don't will be examples like

"Unable to obtain V/S, patient refuses physical assessment"

"Unable to obtain additional V/S due to short transport and multiple patients." (We transport two patients on one truck if injuries are not too severe...this has bitten me in the butt before though)

"Unable to obtain BGL due to equipment failure"

These are some examples I can think off the top of me head. Generally though 95% of your patients you can do everything to the best of your ability.

What I found to help me was to think up scenarios, try to get all forms in. Do some mundane calls, transports, traumas, etc. If you can find an EMT or Medic who precepts new students (or your teacher if you're still in class) see if they will look at your mock run forms and evaluate them. Most states have a 'state default' form you can download from your states EMS website.

Some example scenarios to write up:

Trauma (can be anything from a minor fender bender to major traumas)
Elderly person who fell 1 week ago, feels fine but would still like to get checked out just in case.
Middle aged person with abdominal pain
BLS full arrest
Seizures
etc

Do 1-2 a day, and you should start to fall into a rhythm. If you work try to make sure you do a complete set of paperwork before clearing the hospital. Your partner will need to be patient while you learn.
 
Dominion said:
As a basic, you should not really have to document why you didn't do something ,unless it's related to a short time period or there are specific circumstances.
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...and this is exactly why I mentioned it. There's essentially a rule 34 for EMS scenarios and actual runs. If you can think of a scenario, it's happened.
 
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Dominion said:
As a basic, you should not really have to document why you didn't do something ,unless it's related to a short time period or there are specific circumstances. For the most part you should be able to perform all of your skills on every patient.

I'm currently a Paramedic Student, I haven't used this skill since my basic, that is why I needed some refreshment. TO ALL WHO HAVE REPLIED... thank you so so much for all your help. As I began writing them it started to come back to me with your help. I think I still need a lot of practice though. Thanks so much!!!::)
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As stated in a previous response, I am a retired volunteer firefighter/EMS First Responder. Our FD uses a two-page medical form similar to a NFIRS fire reporting form. As a first responder, trying to read one of the reports filled out by some of our EMT's and Paramedics is a problem when it comes to the abbreviations. If, for some reason, I were to be called into court to testify, and this report was the only ammo I had, I could be screwed. Just remember, plain English beats abbreviations anytime; it may not be a "professional" EMS person trying to decipher a report.

As an example, one of the examples posted used an example of starting an IV. I followed everything, including left forearm, one liter normal saline, but what the heck does TKO mean? Remember, we're a volunteer fire dept. (non-transport) that backs up Rural/Metro Ambulance, whose employees make up many of our firefighters. We are only certified to First Responder level, so we're strictly non-invasive.
 
Theoretically the only person testifying about the contents of a report in court should be the person who wrote it. The only way I can see someone else testifying about them is if the contents are being challenged. I'm not sure why you would be testifying about what happened in a report someone else wrote.

That being said, not going over the top with abbreviations is good. There are some that are standard across the board though, and you might want to do training on them so your fire fighters are familiar with them.
 
Michael Sykes said:
As an example, one of the examples posted used an example of starting an IV. I followed everything, including left forearm, one liter normal saline, but what the heck does TKO mean? Remember, we're a volunteer fire dept. (non-transport) that backs up Rural/Metro Ambulance, whose employees make up many of our firefighters. We are only certified to First Responder level, so we're strictly non-invasive.
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Generally if you WANT to use abbreviations (which I do when I'm trying to be short and sweet) you want to use RECOGNIZED medical abbreviations. TKO is a recognized medical abbreviation that almost every person working in the ED should recognize or you may see c with a line over it which means 'with' or an s with a line over it which means without.

sz = seizure
tx = treatment
q = every (for example "Give Nitro q 5 minutes")
A/O x 4 (Alert and oriented times whatever number)

Those are a few examples of accepted abbreviations in the medical field. You don't want to write a report that is 90% abbreviations.
 
Funny side note...my grandmother was a nurse for 30 years from the 40s-50s to the 80s I think. I while back I inherited something from her, there was a note with it that had been written in 1958. In the note she used the /c as 'with'. I didn't realize that abbreviation had been around for that long.
 
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