Also, documenting in what position the pt was found is important too (for Medicare). But like I said, I'm always looking to see what else I could write.
Write what you find. Your assessment should be based on your knowledge and the patients condition, not what needs to be documented.
1. What else would you write for a transport back to patient residence besides the obvious?
3. Dialysis run?
Patient found A/O x 4 in hospital bed following an admission for ____ and is being transported to ____. Following receiving report, the patient was [assisted/moved via draw sheet] to the gurney. Patient transported in position of comfort with side rails and seat belts. V/S monitored. No change noted during transport. At destination, patient was [assisted/moved via draw sheet]to [bed/wheelchair/ chair] and left in care of [RN, family, etc].
A few quick notes: Allergies, medications history, ABCs, skins, lung sounds, vitals, and a few others are normally check boxes found elsewhere on PCRs. Also, anything abnormal such as coughing can be added easily.
2. What would you write for an emergency for sepsis (from nursing homes I always inspect the pt prior to putting he/she on my stretcher)?
You will most likely need a continuation sheet for this style given the average size of the narrative boxes. Additionally, while the style is somewhat rigid, you can add and subtract from all of the boxes as need be. There's two huge, albeit very related, benefits from this style. SOAP notes are THE STANDARD for documenting a medical history and physical. Any physician should be able to pick up a properly formatted SOAP note and understand exactly what you're saying. Additionally, once you're familiar with the SOAP format, it will make reading the H&P found in patient packets much easier.
Now, admittedly, not everything is needed for all patients, nor necessarily important depending on the patient's status. I wouldn't necessarily worry about the sexual history in a septic patient, but a female with abdominal pain this becomes important. Similarly, a family history is very important in a patient with chest pain. Another problem is I don't think it's necessarily appropriate for documenting a patient found in cardiac arrest.
If I was working on an ambulance now, for emergency calls I would use a format that I've termed "P-SOAP-D." The reason for the "D"[elta] is that a prehospital patient care report is essentially a history and physical combined with a progress note.
Formatting note: This is not in one continuous paragraph. Subject headings are just that. If something is prefaced by an asterisk, then it is its own paragraph. The function of this is to cut up the information so that specific pieces of information can be easily found if it needs to be referenced.
Prearrivial:
Unit 75 was dispatched code 3 to XYZ nursing home for a patient with a dispatch complaint of altered mental status. During the response we were delayed at an at-grade railroad crossing for approximately 3 minutes.
Subject:
*History of present illness (HPI): Patient is a 75 year old male with a chief complaint of an altered mental status. The patient was found unresponsive in his bed approximately 20 minutes ago from nursing staff. According to the RN, the patient developed a fever which was controlled using Tylenol. The patient's temperature last night was ___ and temperature prior to calling us was ___. [insert rest of current history. OPQRST goes here. Etc]
*Medical History:
*Surgical History:
*Medication: (include dosing and what for)
*Allergies: (include what the reaction was)
*Family History:
*Social History: (drugs, alcohol, tobacco, sexual history, occupation, etc as important)
*Review of systems: (questions that you ask)
**General: (e.g. weight gain/loss, dizziness, loss of time, fever, chills)
**HEENT:
**Neck:
**Cardiovascular:
**Resp:
**Abdomen
**GU
**Extremities
**Skin
**Neuro
**Psych
Objective: (physical exam)
*Vital signs: (Pul, resp, BP, temp)
*General:
*HEENT:
*Neck:
*Cardiovascular:
*Resp:
*Abdomen
*GU
*Extremities
*Skin
*Neuro
*Labs/tests: BGL, EKG would be the two big ones for EMS
Assessment: (complaint followed by working/differential diagnosis)
Altered mental status: Sepsis, [other differential diagnosis]
Plan:
___ bore IV started on first attempt at ____ with fluids ran wide open. ___ fluid administered during transport.
Patient transported in semifowlers code 3 to ____.
Sepsis alert called in route. [other treatments, etc]
[I would give each intervention on it's own line so that you can document the particulars of each intervention, such as number of tries, confirmation, site, etc as appropriate]
Delta:
[document patient's response to treatments and close with the transfer of care]
