HELP...Run Report Narratives

[Lvillemedic]

Pertinent Negatives..Don't forget these!!!!

Something I always add is the pertinent negatives..i.e. Pt c/c of rapid heart rate, but pulse normal and NSR on monitor, or showing STEMI with out physical signs or symptoms also known as a silent MI..

As for abbreviations: Do not use ETOH unless you can fully state what ETOH is..besides alcohol intoxication... an attorney will eat you alive in court. I alway use "smells of alcoholic beverage" because alcohol by it's self has no smell or color....I also like the little triangle that stands for changes and is well known in the hospitals......Atleast around here....

 

[JPINFV]

To be fair, it should be EtOH. Actually, thinking about it now, I'm tempted to put CH3CH2OH. (also, purely technically speaking, alcohol is bad to use. Methonal poisoning is a type of alcohol poisoning)

 

[akflightmedic]

Something I always add is the pertinent negatives..i.e. Pt c/c of rapid heart rate, but pulse normal and NSR on monitor, or showing STEMI with out physical signs or symptoms also known as a silent MI..

As for abbreviations: Do not use ETOH unless you can fully state what ETOH is..besides alcohol intoxication... an attorney will eat you alive in court. I alway use "smells of alcoholic beverage" because alcohol by it's self has no smell or color....I also like the little triangle that stands for changes and is well known in the hospitals......Atleast around here....

Exhibits or displays behavior consistent with substance abuse...then mention slurred speech, staggering, quotes, smells, etc. Not saying he is or isn't, but describing behavior consistent with it all. Just be sure he doesnt have low BGL or a head injury.

 

[MRE]

Just be sure he doesnt have low BGL or a head injury.

I have always found it interesting, how several completely unrelated ailments can present as intoxication, and have tried to educate people about them. We had a guy crash his pickup in the parking lot of my payin' job, and many people believed it was due to ETOH, just because of the nature of the incident. Turns out that the guy had some kind of allergic reaction to a shot he got earlier that morning, causing him to enter an altered mental state and finally go unconscious with his foot on the gas.

 

[ecampvet]

BART-Body Assuming Room Temperature
DWPA-Death With Paramedic assistance
ABC-Ambulate Before Carry

I use Dispatch-CC-HX-***-RX/TX-EXTRA

We use the all-too-horrible Zoll E-PCR so everything is already on the form so only a brief overview is really necessary.

GOMER-Get Out Of My Emergency Room

 

[ecampvet]

WNL= We Never Looked

 

[Jim37F]

We use a simple chronological narrative of what we saw and did.

"(Age)(M/F) found (position found) A&Ox_ (AVPU if not A&O) c/o (complaining of)____ 2° to (MOI). Pertinent positives. Pertinent negatives. Any additional injuries/acute medical issues found (e.g. c/c SOB w/ no CP but found an acute arrhythmia on the monitor). Treatment(s) rendered. Transported to (Hospital) for (eval and treatment/definitive care/specialty center (Stroke, STEMI, Trauma, etc.)"

Example: "85 y/o M Pt found sitting upright in chair inside store. Patient A&Ox3/4 (- event) with repetitive questioning. Pt c/c left arm pain and neck and back pain 2° to mechanical slip and fall backwards off approx. 4 steps with loss of consciousness and unable to remember event and seems dazed and confused. 1" hematoma found on back of patients head. L forearm bruised and tender. No other injuries found. Pts placed in full SMR and L arm splinted. Pt transported C3 to (Trauma Center). Pt monitored enroute with -changes."

 

[NomadicMedic]

Here's one of mine:

Med 1 responded priority to a 57-year-old female at a private residence with a complaint of abdominal pain. Patient related that about 40 minutes prior she began vomiting, with a sudden onset of severe abdominal pain. She related there was no blood in her emesis. Her last oral intake was approximately six hours before, consisting of a sandwich, which was a normal meal for her. She related that she had both her appendix and her gallbladder and has never experienced gastro distress of this type before. She also related that her last bowel movement was approximately three days ago. She has had a hysterectomy. Aside from the abd pain, she had no other complaints. She related a history of hypertension and back and knee pain, secondary to arthritis, for which she was under treatment. Her medications are listed above, and she has no drug allergies, but is allergic to latex.

On EMS arrival, the patient was found on her hands and knees, next to her sofa, complaining of 10 out of 10 abdominal pain. Patient was warm and dry, breathing regularly and had a normal pulse rate. No immediate life threats were noted during the initial exam.

The patient was assisted in standing and taking several steps to the ambulance stretcher, which was placed at the door to the house. The patient was assisted to the stretcher and secured with all straps and then moved to the ambulance for additional treatment and none merge t transport to Xxx Hospital.

In the ambulance the patient was placed on the cardiac monitor and found to be in sinus rhythm at a rate of 70. There was no ectopy noted. Patient's BP 126/80, blood sugar measured at 118. The patient was placed on 2 L of oxygen via nasal cannula and SPO2 was 100%. IV access was obtained in the left AC with a 20 gauge catheter and secured with 10 mL of normal saline and a lock. Patient received 4 mg of Zofran slow IV push and the IV was flushed with 10 mL of NS. A telephone report to xxxx hospital was made, advising the patient's condition and ETA. Patient was monitored for changes during transport, and the patient related relief from her nausea. Transport was without incident.

On arrival, the patient was moved to treatment room one, assisted to the bed and all rails were raised. A verbal report was given to the RN at bedside, and the patient's pocketbook was left in possession of the patient. Signatures from the patient and the RN were obtained, a copy of the privacy policy was left with the patient and med 1 returned to service

 

[Jim37F]

^ That's awesomely detailed, only problem is that it's about 5 times bigger than the amount of space we have for a narrative on our run forms.

 

[NomadicMedic]

Wow. That sucks.

I've said it before, and I'll say it again, your outlook on narratives will change about 5 minutes into a deposition.

 

[cruiseforever]

^ That's awesomely detailed, only problem is that it's about 5 times bigger than the amount of space we have for a narrative on our run forms.

Is it EPCR or paper PCR? If it's paper I would start a second form. I find the EPCR that we use will record as much detail as I care to write.

 

[Angel]

uh...i use the "CHART" method and it seems to work just fine. if its not pertinent to the issue at hand its not likely to be included (though in some cases if it helps with the back story it will be)
i like to keep it short, sweet and to the point.
you have good examples so unless you really want one from me...ill let you stew on that.

it will take time to develop your own style, but i say pick one from a partner or supervisor and stick to that format until you're comfortable to venture away on your own. But keep in mind, as others have stated, it could end up in court so be as specific as possible without being redundant or providing irrelevant information. (which only you would know if it is relevant or not)

ETA: he shouldnt need a second form if hes being precise and using short hand. (my county and most have an approved abbreviations list) The only time I ever used a continuation is when I was new.

 

[NomadicMedic]

...or use the charting standard that you department or company wants. One you find a system you like, stick with it.

 

[Angel]

If that was the case I don't think this thread would've even been started. Most, in fact none of the places I've worked care what method you use as long as certain information (ie billable) is included. I use different formats for 911 vs IFT because there really isn't much done for transfers besides monitoring.

 

[NomadicMedic]

Funny, every agency I've worked for, both private and government, 911 and IFT, all had charting standards.

I'm used to twisting my standard narrative around to make it fit the standards.

 

[Brandon O]

Here's one of mine:

This is beautiful. If you want any input, though, I would suggest you can omit all the "she related" and similar fillers ("pt states," etc). It can be presumed the source of information for a patient history is the patient unless otherwise noted.

 

[gotbeerz001]

^ That's awesomely detailed, only problem is that it's about 5 times bigger than the amount of space we have for a narrative on our run forms.

I'm sure there is a Form B with more room for a narrative.

 

[Angel]

Yea, the standard of being billable, that's what I said.

 

[Jim37F]

Well a unique issue for my current departments ePCR that I don't think any of you guys have to deal with is that it pretty much HAS to be written by the Paramedic on their iPad, and then transferred to our unit's iPad before we can transport BLS. In a decision that apparently made sense to the chief officers who decided on it,w hen they do so, the software on our BLS iPad locks out many features, including the narrative. I literally cannot go in and edit the narrative. IF I catch the engine medics before they leave I can push the form back to them and they can change/edit and then push back to me, but if they're already gone...well it is their signature on the form....Not my favorite answer by any means but sadly thats the way it is here.

But for the old paper PCR's we keep as backups, along with those of both the private companies I used to work for, the forms were of the ilk that you had to press hard while writing to transfer to three different pieces of paper (one stayed with the company for our records, one stayed with the patient for their medical records, one went to the County EMS office and so on) so if I REALLY wanted/needed to write a second page, I'd have to start a whole second PCR and include all the other bits of header data (Pt info, pickup and dropoff locations, dispatch/enroute/onscene/transport/transport complete times, vitals, EVERYTHING) would have to be replicated in order to do a narrative continuation on a second page, now where the narrative box will literally only fit one of those 5 paragraphs DE wrote....well you can see redoing 6-8 PCRs 5 times each over the course of a single shift would simply become a huge hassle that would have gotten me hauled into the supervisors office asking why I'm wasting so much paper to write out so much redundant detail already covered in other places on the PCR.

It was simply not realistic on routine PCRs to write out such a long and detailed narrative. The only official Page 2 we have is specifically for advanced ALS procedures like intubations and cardiac arrest resuscitation.

Since I'm not at work I don't have access to a blank copy of my current PCR software, but it's one of those programs designed to look just like a single page paper PCR that you then tap on a section and it brings up the appropriate boxes to edit info, and once your done is designed to look just like a paper PCR you scanned in (versus some others I've seen full of tabs and pages where you can write endless amounts of info). In fact our base hospital makes us print out a copy and since they're rather stingy with printer paper and toner we are supposed to keep it to the one page so that one paragraph box is all we have to work with.

I do have a blank PCR from my previous job so you can see the space I had to work with, and the lack thereof to write novels for every single patient. Also I'm attaching a copy of my current official narrative writing guidance.

 

[CALEMT]

so if I REALLY wanted/needed to write a second page, I'd have to start a whole second PCR and include all the other bits of header data

You don't have addendum forms to where you don't have to refill out everything? Interesting.