I'm a very very new EMT and I recently had my first training shift and was given some homework to create 2 sample narratives.. I was wondering if anyone had some good outlines they usually go by in their reports so I can get a feeling for the right amount of information necessary in a narrative.. Thanks!
Helping a newcomer create a good outline for narratives
SandpitMedic
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planetmike
Forum Lieutenant
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I like using the DCHARTE method. Each letter gets a paragraph of detail about the call. Each letter is roughly in chronologic order.
D: Dispatch information: What were you sent to? What units. Lights and siren? Where did you go? Where did you find the patient?
C: Chief complaint: usually one sentence, in the patient's own words, put inside quotes.
H: History: History of both this specific medical problem or traumatic event. Include also patient history, such as allergies, medications, surgeries, illnesses, etc...
A: Assessment: How old is the patient? A&O? ABCs? on scene vital signs? Other assessment details. Answers to any questions you asked the patient.
R: tReatments: Any treatments you performed. At the BLS level, this may be quite brief.
T: Transport: Did the patient want to be taken to a facility for further assessment and treatment? How did the pt get from where you found them to the ambulance? How were they secured? How did you get the pt to the hospital (lights and siren)? What happened during transport? Vital signs were taken? Pt was monitored? And treatments? Was hospital contact made by radio/cell phone? On arrival, where was the patient left (ED room bed, triage, hall bed)? Document the report you gave to whoever at the ED. Care was transferred.
E: Exceptions: Anything odd that happened. Example: Reason pt couldn't sign forms. Pt refused backboarding.
Then complete with stating that your unit cleared the hospital/facility without incident, your name, and certification level.
It takes a lot of repetition to learn documentation. Just stick with it. Some people at my agency absolutely hate using the CHART method. Use what works for you and your agency. Remember you are painting a picture of the patient. If you don't write it down, it wasn't performed. Remember, in X years, when this patient sues you and your agency for something they and their lawyer feel you did wrong, this is your primary (only?) evidence of what happened on the call.
D: Dispatch information: What were you sent to? What units. Lights and siren? Where did you go? Where did you find the patient?
C: Chief complaint: usually one sentence, in the patient's own words, put inside quotes.
H: History: History of both this specific medical problem or traumatic event. Include also patient history, such as allergies, medications, surgeries, illnesses, etc...
A: Assessment: How old is the patient? A&O? ABCs? on scene vital signs? Other assessment details. Answers to any questions you asked the patient.
R: tReatments: Any treatments you performed. At the BLS level, this may be quite brief.
T: Transport: Did the patient want to be taken to a facility for further assessment and treatment? How did the pt get from where you found them to the ambulance? How were they secured? How did you get the pt to the hospital (lights and siren)? What happened during transport? Vital signs were taken? Pt was monitored? And treatments? Was hospital contact made by radio/cell phone? On arrival, where was the patient left (ED room bed, triage, hall bed)? Document the report you gave to whoever at the ED. Care was transferred.
E: Exceptions: Anything odd that happened. Example: Reason pt couldn't sign forms. Pt refused backboarding.
Then complete with stating that your unit cleared the hospital/facility without incident, your name, and certification level.
It takes a lot of repetition to learn documentation. Just stick with it. Some people at my agency absolutely hate using the CHART method. Use what works for you and your agency. Remember you are painting a picture of the patient. If you don't write it down, it wasn't performed. Remember, in X years, when this patient sues you and your agency for something they and their lawyer feel you did wrong, this is your primary (only?) evidence of what happened on the call.
NysEms2117
ex-Parole officer/EMT
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Documenting "normal calls" is easy, just write down everything that happened, when you did anything medically related, and any contact you had with a "higher medical authority"... Documenting RMA's is difficult and i personally write my own narrative for RMA's. That narrative includes: Releasing me from all medical care, patient understands what i explained, patient is confirming they are the name signed on the RMA, they know all risks to there health up to and including sudden death. However, thats the LEO in me though.
NomadicMedic
I know a guy who knows a guy.
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You'll also learn that you'll want/need to include specific items in every narrative. Things that you need tigger in the habit of performing on calls and then documenting. Things like "or moved to wretch and all straps, including shoulder harness, were fastened", "patient placed in ED bed 6 and rails raised", "patient's personal items; glasses and ID card, were left with the patient at time of transfer of care", "a verbal report was given to Kelly Doe RN at bedside."
Most EMTs document the patient care mostly correctly, but get hemmed up on simple details that come back to bite you when something goes wrong. A patient falls out of bed. A patient can't find their glasses. The truck gets hit and the patient isn't appropriately secured with stretcher straps.
Get in the habit of doing it right and document the things that show you not only provided good patient care but you also provided good customer service, safety and concern for the patient in general.
Most EMTs document the patient care mostly correctly, but get hemmed up on simple details that come back to bite you when something goes wrong. A patient falls out of bed. A patient can't find their glasses. The truck gets hit and the patient isn't appropriately secured with stretcher straps.
Get in the habit of doing it right and document the things that show you not only provided good patient care but you also provided good customer service, safety and concern for the patient in general.
Gurby
Forum Asst. Chief
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What information you do or don't include will depend on what the rest of your PCR looks like. For example, I'm required to input meds / history / allergies elsewhere in the PCR, so I don't clutter my narratives with that info. I used to write all that stuff about securing straps, raising rails, etc, but recently decided "whatever, it'll probably be fine...". As far as I'm concerned those things should just go without saying.
My reports follow a kind of modified SOAP method. I do a paragraph for subjective-ish, paragraph for objective-ish, and then treatment/transport. 95% of them go like this:
Paramedic 37 dispatched to above address, single family home, for "the unknown medical". On arrival, contacted 90yo female. Patient states that she awoke this morning at 4:30am with chest pain etc etc. Patient rates pain at 8/10, "heavy" in nature, radiates down left arm and to jaw. Patient states has had MI in the past and it felt similar to this. Put all the "subjective" things here, what the patient tells you, when was the last known normal if it's a stroke. If it's an MVA I put "airbags deployed, patient states was wearing seatbelt" etc.
Patient is alert and oriented to person and events, but not to place/time (husbands states this is baseline, patient has hx of dementia). Skin cool pale diaphoretic, pupils ERRL, neurologically intact. Lung sounds: coarse rales noted bilaterally. 12 lead EKG shows whatever. If it's a trauma, I put relevant findings here. Next I put any abnormal vital signs BP 80/50, HR 120, SpO2 70%. If they were fine I just write "hemodynamically stable".
Administered O2 at 15Lpm via NRB (SpO2 improves 70->80). Administered other things (effect?). Transported to Jimbob Hospital ED: STEMI ALERT called. On arrival, report given and care transferred to facility MD and RN. P37 clear.
My reports follow a kind of modified SOAP method. I do a paragraph for subjective-ish, paragraph for objective-ish, and then treatment/transport. 95% of them go like this:
Paramedic 37 dispatched to above address, single family home, for "the unknown medical". On arrival, contacted 90yo female. Patient states that she awoke this morning at 4:30am with chest pain etc etc. Patient rates pain at 8/10, "heavy" in nature, radiates down left arm and to jaw. Patient states has had MI in the past and it felt similar to this. Put all the "subjective" things here, what the patient tells you, when was the last known normal if it's a stroke. If it's an MVA I put "airbags deployed, patient states was wearing seatbelt" etc.
Patient is alert and oriented to person and events, but not to place/time (husbands states this is baseline, patient has hx of dementia). Skin cool pale diaphoretic, pupils ERRL, neurologically intact. Lung sounds: coarse rales noted bilaterally. 12 lead EKG shows whatever. If it's a trauma, I put relevant findings here. Next I put any abnormal vital signs BP 80/50, HR 120, SpO2 70%. If they were fine I just write "hemodynamically stable".
Administered O2 at 15Lpm via NRB (SpO2 improves 70->80). Administered other things (effect?). Transported to Jimbob Hospital ED: STEMI ALERT called. On arrival, report given and care transferred to facility MD and RN. P37 clear.
As a rule of thumb, your FTO was supposed to give you a sample narrative in your company's approved format. If they didn't do so, you need to clarify this matter with them. Different companies will always have specific things they'd like to see in the narrative, and that isn't something anyone here can help you with (unless they work for the same system). As for the general outline, as others have said - your narrative is a brief description of the call, with as little clutter as possible. Ex: arrived on scene to find a X y.o. M/F, AOx(whatever), in x position & x level of distress, for (nature of call). Then you list the objective part, i.e. their Hx if available, meds, C/C + 2ndary complaint (if any), pain lvl etc. Next you document what and why you've done for the patient (medicine administration/route, moving, positioning on the gurney, position adjustment if applicable, restraints if needed, vitals etc). And lastly, you document what you've done when you arrived at the receiving facility i.e. where/how you left the patient, who did you give report to (title & name are usually enough) and how the care was transferred.
Best thing you can do is, once you have your company's template and requirements, practice in writing sample narratives a few dozen times. Once you've written enough, it'll become a 2nd nature. Just follow the same routine every time til it sinks in.