Narrative Section of Documentation

[77E12]

This question is regarding the narrative section of the run sheet.
The captain of my squad has told us not to write a narrative for calls, but rather to put a big "X" in the box.

Her reasoning is that, if we are called into court one day or if someone questions the legality of our actions on a call, the narrative could cause us to "trip over our own words."

I've only been an EMT for about a year, but I remember the narrative being an essential part of the documentation chapter of the text, and the instructor pounding into our heads "write EVERYTHING down" to cover ourselves legally. Maybe the Captain's right, who knows?

I'm anxious to read what everyone else has to say about this issue.

 

[ffemt8978]

Originally posted by 77E12@Aug 12 2004, 05:41 PM
The captain of my squad has told us not to write a narrative for calls, but rather to put a big "X" in the box.

Her reasoning is that, if we are called into court one day or if someone questions the legality of our actions on a call, the narrative could cause us to "trip over our own words."

Attorneys can only trip you up on your own words if you don't document everything, and try to answer them in a manner which gives them an opening.

ALWAYS, ALWAYS, ALWAYS DOCUMENT EVERYTHING!!!!!

If you get called into court a few months or more likely a couple of years down the road, the only thing you will have to remember the call is your report. You are allowed to refer to your notes (read report here) to refresh your memory. You are not allowed to make answers up off the top of your head because you don't remember the specific incident.

Do you remember where you were, what you observed, and what you did about it two years, three months, and four days ago at 0811?

ALWAYS, ALWAYS, ALWAYS DOCUMENT EVERYTHING!!!!!

Also, if you get into a malpractice or negligence lawsuit, you lack of documentation will kill you. Might as well retire from EMS and write the patient a hefty check.

 

[MMiz]

Originally posted by 77E12@Aug 12 2004, 07:41 PM
This question is regarding the narrative section of the run sheet.
The captain of my squad has told us not to write a narrative for calls, but rather to put a big "X" in the box.

Her reasoning is that, if we are called into court one day or if someone questions the legality of our actions on a call, the narrative could cause us to "trip over our own words."

I've only been an EMT for about a year, but I remember the narrative being an essential part of the documentation chapter of the text, and the instructor pounding into our heads "write EVERYTHING down" to cover ourselves legally. Maybe the Captain's right, who knows?

I'm anxious to read what everyone else has to say about this issue.

77E12,

First, welcome to the forum!

I had to read your post twice before I responded. Are you kidding? I was always taught to document EVERYTHING, and everyone in the field tells me to document EVERYTHING. That narrative portion of the form is quite possibly the most important. I asked the senior medics who have been working for 15+ years why the write so much on the forms, and they all tell me about that one time they were called into court. Here is was our company requires on all calls:

B123 dispatched P3 to 123 Main Street for unknown medical. ATF 14Y/O male supine on ground...blah blah blah.. C H A R (T) Pt moved to ambulance cot with full assist. Pt secured with straps x3, covered w/ linen, rails raised. Secured in ambulance. blah blah blah. Pt moved to hospital cot with full assist. Rails raised.

That's just a short part of our form, but they're anal. I havent been in EMS long enough to go to court, but I understsand its part of the job. Whether it be you or one of your corworkers, I think everyone who has been in EMS for a while has been in court.

On the same note, I notice many FF/Medics have short reports with little info. They still have a narrative though. I've never seen someone write an X through the box. With 10% of all my BLS transfers, and 100% of my emergency calls going to CQI (company requirement), I would get in trouble.

I sure wouldn't put a career, or even life on the line for such a small thing.

 

[cbdemt]

HUH!?!?!?!?!?!

To quote my EMT-B instructor...
"If you didn't write it, it didn't happen"

 

[MMiz]

Originally posted by cbdemt@Aug 13 2004, 08:34 AM
HUH!?!?!?!?!?!

To quote my EMT-B instructor...
"If you didn't write it, it didn't happen"

What is also what I've been taught, and what every supervisor I've talked to tells me.

 

[Firechic]

Ditto - I was taught to document everything.....if you didn't write it - it didn't happen and you didn't do it and that's a big NO NO in court.
If I was a lawyer, I'd have a field day with the big "X" narrative. Those types of lawyers know what should or should not be on those reports already.
What it comes down to is that if you have to go to court over something, chances are lawyers will rip you apart no matter what you put down - better be on the safe side and use that standard of care which I always thought was to document a narrative.

 

[croaker260]

It is very seldome that I will say something is wrong, I uusually try to understand others views, etc....Medicine is an aert, not a cookbook with only one recipe.

But in this case, I will say it..that is absolutely wrong to document in such a poor unprofesional fashion.

I personaly prefere the SOAP format. With few adaptions it not only makes an excellent EMS report, but looks profesional in court, and looks remarkably similar to MD's dictation..which is what we should use as a basic bench mark for sucess.

Just my thoughts. I know some peopel prefer CHART, and some even Narritive (though I cant personaly say I like either of those two methods), and some even like computer generated charts from click boxes...again cant guess why other than speed, but its their chart, not mine...but to not document a narritive at all...unacceptable.
Thats point blank and period.
Any questions?

 

[MMiz]

croaker260,

I take it you are talking about my style? Or was that not documenting at all? Unfortunately this is a company policy, not a personal choice. My personal favorite is the SOAP also, but it is a company mandated policy that everyone uses CHART, along with the little blurb I initially posted.

 

[rescuecpt]

The EMS director for the NYS Department of Health has been inspecting PCRs (Pre Hospital Care Reports as they're called here) statewide and "visiting" departments with less than perfect reports. He will read your report outloud, tell you what he understands from it, how your care was deficient and dangerous, and then have you try to argue that you did what was proper. Everything you say that's not on the PCR, he'll say "no you didn't, it's not written down".

If you don't fill out the narrative, how will anyone be able to prove what was and wasn't done? It will become your word against the patient or the patient's lawyer... and I can bet you their lawyer will be better than the one your volunteer or paid post will send to "help" you.

 

[croaker260]

Originally posted by MMiz@Aug 13 2004, 10:18 PM
I take it you are talking about my style? Or was that not documenting at all? Unfortunately this is a company policy, not a personal choice. My personal favorite is the SOAP also, but it is a company mandated policy that everyone uses CHART, along with the little blurb I initially posted.

I was refering to the not documenting at all part. I was just "comparing and contrasting" by listing the way some people write, not being judgemental (unless offering my own comment on my preferences is judgemental..then Im guilty )

So no I wasnt saying CHART is unacceptable, just not documenting. I will say it would be an intersting thread if everyone would talk about what style they like , defend their choice, and maybe even discuss what they put where in their preferered method.
For example SOAP: I believe that vehicular description and scene description is an objective finding (unless you were not able to inspect it yourself), therefore goes into the "O"..there are others who disagree. I think that would be an interesting thread, would someone care to start it? Or maybe it would bore everyone to tears..but since I am very documentation oriented, it would just illustrate what an EMS geek I really am...even after all these years...
Steve
P.S. I do think its a god idea that everyone in a department use the same basic style in documenting charts.

 

[rescuecpt]

We don't use SOAP or CHART - I don't even know what those stand for... I'm assuming in a way we do. In NYS we have two types of PCRs (Prehospital Care Report), medical and trauma. Each report is a 3 copy (white, yellow pink) carbonless paper system with all the required and extra info categorized into boxes. The absolute must haves are shaded grey, the rest are plain white but it is heavily suggested that everything be filled in completely.

The major medical PCR categories include:

- agency info (name, number, run number, vehicle number, times, etc)
- Pt information (name, address, birthday, age, social, doctor, etc)
- chief complaint (what patient states)
- subjective assessment (describe what we see when we arrive)
- check off boxes for presenting problem (what we see)
- Pt history (allergies, medications, CVA, cardiac, COPD, asthma, diabetes, hypertension, seizures, etc)
- 3 sets of vitals (time, resp rate & quality, pulse rate & quality, BP, GCS, pupils, skin, transport status)
- objective assessment (I usually write PE (physical exam) and list all my findings and pertinent negatives, starting with the head and finishing at the toes)
- comments (other things you've heard, observed, etc.)
- check off boxes for treatements given (20+ including O2 delivery, medications, IV's, movement of patient via stretcher, stair chair, backboard, etc)
- Disposition (hospital name and disposition code)
- Crew information (Crew Chief name, EMT #, and skill level (CFR, EMT-B, ALS), Driver name and info, crew member #1, and crew member #2)

The trauma PCR has all the same information, including check off boxes for MOI, safety devices employed, a diagram of a vehicle to mark intrusions, collision damage, etc, and a front and back diagram of the body to mark off pain, contusions, abrasions, lacerations, etc.

 

[ffemt8978]

I posted this in a previous thread, but I'll post it again.

Washington state actually requires us to use the SOAP format. At my previous department, our reports were written in the exact same manner that we gave our run reports.

I have two problems with the SOAP format, though. The first is that there can be a lot of information repeated (in a different way) between the S and the O portions. Also, our medical director wants us to enter a very specific assessment. Instead of RUQ Abdominal Pain, we have to put the following: Poss. Gall Stones, Poss. Appendicitis, Poss. GI Bleed, Poss. Hepatitis, Poss. Ectopic Pregnancy (females only). My concern with this is getting hauled into court and having a lawyer rip into me about my diagnosis/assessment (don't kid yourselves, assessment can be considered a diagnosis in court).

I asked why the SOAP format was required, and was told so that the hospital can look up specific information when needed. I agree that a standard format is nice, but shouldn't they be reading the whole report instead of bits and pieces?

I still believe the SOAP format has some serious deficiencies with it. First of all, the repetition of information between the various fields. Secondly, it doesn't logically follow your treatment. For example, you document in the S section that PT c/o LT arm pain, in the O section PT had obvious deformity and abrasion injury to LT arm, in the A section PT had possible broken arm with soft tissue injury, and in the P section Bandaged and splinted LT arm in place. Now this may seem like a logical plan until you realize the additional information that is found in each field. Under the S, you have the complete PT Hx, Allergies, Meds, etc...; under the O you have your scene observations, vital signs, head to toe survey, etc...

 

[croaker260]

WHAT is SOAP and CHART??
They are two narritive styles. There are good and bad examples of each. Now below it is going to sound like I think anyone who doesnt write SOAP is wrong, or a bad medic, or something..not the case..Write a good chart, and if it works for you then it works for you. But here is my method, my version of SOAP, and what we use here in Boise.

S- Subjective, in other words what your told and what you read in previous charts. Includes primary and secondary complaints, pert. negatives, OPQRST, SAMPLE, etc.
Example:
Pt is a (adult) y/o male with complaint of general non-specific left side “Aches and Pains” post MVC. Pt reports he was a fully restrained driver in a vehicle (older large sized sedan) that the accelerator apparently stuck on, reportedly causing the pt to lose control in a curve and slide into a vehicle. Impact was to the left side of the vehicle. Estimated speed is 35-40 MPH, no LOC, positive ambulatory post MVC. No neck or back pain, no nausea/ vomiting, numbness/tingling, chest pain, abd pain, or other priority s/s.
Pt denies any recreational drug or alcohol use

O- THis is what you personally see and assess. Traditionally your head to toe, in EMS this extends to scene survey assessments like height of tree they fell from or vehicular damage. Also includes all "Diagnostics" like an EKG or a Blood Sugar.
Example:
GENERAL: Adult male sitting in passenger side of a vehicle, attended by QRU.
VEHICLE: Older Cadillac, full sized sedan, with a single impact noted on drivers side of vehicle. Impact is just being of the drivers B post, with no intrusion into pt compartment nor any intrusion onto the pt. Glass window next to driver seat is intact. Steering column, dash, and windshield is intact.
PRIMARY: LOC: CA&Ox3, calm cooperative. A: Clear B: non labored C: Skin PWD, no cyanosis. D: Moves all ext well, no deficits. Speech is clear.
SECONDARY: HEENT: Atraumatic. Glasses (which pt was wearing at time of impact) are intact with no visible damage. Tongue intact. Bite even. PERRLA. NECK/BACK: Non tender, stable, no deformity. Full spontaneous ROM of neck noted. CHEST: stable non tender Lungs CTA bilat ABD: soft & supple, non tender . EXT: Atraumatic. No localized tenderness. Full ROM, strength, flexion/extension/rotation and sensation, as well as distal pulses to upper ext noted.
SAO2: 98% on RA

A- Assessment, what we call a working field diagnosis. and yes, its OK to do this. Nursing personnel do , so do we. So do all of the medical profession, Its not practicing medicine with out a license, its doing you job. NOTE: The sum of your S and O should meet up with this. For example you cant put down heart attract unless you document the pt is having some sort of heart attack sighs or symptoms. Example:
Non-specific pain post MVC. No specific injuries identified.

P- A narrative description from pt contact to end of call in wich you document in chronlological order everything that happened in itemized format. example:

-Contact, assessment as noted, spinal precautions deferred per protocol, v/s obtained.
-MD eval recommended post MVC, pt elects for EMS transport to (local hospital.
-Pt assisted to MICU for uneventful sit up transport to (Local Hospital).
-V/S as noted. No change in route.
-On arrival pt, backpack with undisclosed contents at ER with full report to staff RN. EMS clear. Pt completes HIPAA Paperwork.


Here is CHART:
C: Chief Complaint
H-History
A- Assessment findings
R- RX as in treatment given
T- Transport events

First of all, the repetition of information between the various fields. Secondly, it doesn't logically follow your treatment. For example, you document in the S section that PT c/o LT arm pain, in the O section PT had obvious deformity and abrasion injury to LT arm, in the A section PT had possible broken arm with soft tissue injury, and in the P section Bandaged and splinted LT arm in place.

Hmm, I have heard the repetitive information complaint before, I just don’t by into it. Simply put, It is important both what you see and what you are told, even if it is the same. For example..if a pt (or a care provider talking about the pt) tells you they have pneumonia (which you put in subjective), do you not document lung sounds (in the objective) that confirm this? Do you put in your assessment "Pt states he has Pneumonia"? Nope, you put "Probable Pneumonia" or something similar.
If a pt states he has had " A bunch to drink" you document that right (in subjective)? Is it considered redundant to document the "strong odor consitant with alcoholic beverage noted at 5 feet when approaching the pt"(in objective)?
Or how’s this: The pt tells you he thinks the vehicle rolled several times, a clearly subjective statement. Do you not document in your scene survey (an objective finding)that the vehicle has damage to sides and roof consistent with a rollover?

Each section in SOAP stands by it self. Therefore while there is some overlap, it is complementary. Think of it like a criminal investigation, it is important what you are told, it is also important what you see, and the differences or similarities between the two are important as well. Like two different witnesses , MR. S and MR. O telling their own version of what happened, and with out one or the other telling his complete story, then you dont get the complete picture.

Now your probably saying…..yeah yeah , that’s what Im complaining about. OK, so its a little more work, but in my very humble opinion it makes for a great chart, easily read and easily deciphered, and it is consistent with much of the rest of the medical community.

"I asked why the SOAP format was required, and was told so that the hospital can look up specific information when needed. I agree that a standard format is nice, but shouldn't they be reading the whole report instead of bits and pieces? "
Your right, and they frequently do, but its hard (I know, from a QA point of view) to pick apart vital components for analysis with a format that is haphazard or with which you are not familiar. Think of it this way, you don’t write down word for word everything a pt, bystanders, dispatch everyone says, right? No you organize and summarize so as to better paint a picture. And that is likely what the hospital means, they want something they can assimilate quickly, and SOAP allows that.


And not to sound arrogant, Ill put my SOAP up in court anyday.