need help with documentation

[HNcorpsman]

hello everyone, my name is greg and i am a corpsman in the navy, i am stationed in okinawa and my command has finally picked me to go TAD to the firehouse and work as a EMT... one thing, i took my EMT class before i joined the navy and have never worked on a rig, besides in training... i have decent medical exposure, so i think i know that part OK... but as for documentation and some other minor things i might need some touch ups...

i am going to write a sample narrative document and i would like some insight on what you all think... i will be using the standard for military sick call at least SOAP note form... any advice will help immensely.

(this is not an actual document)

upon arrival to scene 19 y/o male PT presents with a productive cough and states that "it hurts to breathe" PT states that "it all started when i was playing football with my friends" PT is seated in the tripod position, PT claims pain to be at level 5. upon questioning PT reveals that he has asthma. PT does not carry or have albutoral or any medication. B/P: 139/79 P: 70 R: 16 T:98. placed PT on NRB, and transported in supine, sitting position. continually monitored PTs breathing, coughing subsided during transport. conducted secondary assessment during transportation to hospital, turned over to medical officer.

well?

tell me what i need to do better...

 

[akflightmedic]

You need to do a lot better but since you asked I will offer a few tips. By no means is what I say final or absolute correct, others may correct me or mention things I overlooked as well.

Here is what you wrote: "upon arrival to scene 19 y/o male PT presents with a productive cough and states that "it hurts to breathe" PT states that "it all started when i was playing football with my friends" PT is seated in the tripod position, PT claims pain to be at level 5. upon questioning PT reveals that he has asthma. PT does not carry or have albutoral or any medication. B/P: 139/79 P: 70 R: 16 T:98. placed PT on NRB, and transported in supine, sitting position. continually monitored PTs breathing, coughing subsided during transport. conducted secondary assessment during transportation to hospital, turned over to medical officer."


Things which jump out immediately are the fact that you did not do or document lung sounds. You did not mention O2 saturation or any other physical findings such as ability to talk in complete sentences, pursed lips, color of skin, etc.

You state that the patient "claims" to be a 5 on the pain scale as if you do not believe him. You also do not reference what pain scale you are using. You did not specify where the pain is, if anything makes it better or worse, etc. Do you know OPQRST?

Along the not believing the pt comments, you also state "upon questioning..pt reveals" again indicating an interrogation or disbelief position on your behalf.

You did not tell me how many liters of O2 he is on with the NRB mask. You did not tell me if he improved in any areas other than coughing subside. Did the coughing subside because he quit breathing? (See where I am going with this?)

How do you transport a patient in a supine sitting position? If you do, I would like to see the prone sitting position for reference.

That should be enough for now to get your brain jogging. Hope it helps!

 

[vquintessence]

supine upright?

AK made the biggest pointers already. What about pts level of orientation? Mention color of sputum and how long the cough has been present. Pt febrile at any point? Any retractions? Where was this pain? ex: if pleuretic, did pain increase during respiration, or by palpation?

You need more pertinent negatives, and I don't care what a lot of people say, EVERY pt needs SOME FORM of physical exam. I personally document the **** out of most calls... here's how I'd re-write a similar fictional version going by only the info ya said. (p.s. I'll assume the pain is pleuretic CP)

<unit #> dispatched <priority #> to residence for reported difficulty breathing. <XYZ other agencies/apparatus on scene>. U/A found 19 Y/O male AOx4 speaking <full sentences or 2-3 word dyspnea or etc> and sitting tripod position.
HPI: Pt reports acute SOB after playing football. Pt pmhx asthma and recent productive cough of <color> sputum for x days/weeks. Pt states pleuretic CP that began following SOB exascerbation s/p football, sharp pain 5 of 10, -radiating and pain increases upon inspiration and palpation. Pt has not initiated any medical interventions.
ASSESSMENT: AOx4, airway patent, breathing <dyspneic, NL, tachypneic> bilat c <wheezing, rales, rhonchi, clear> present at <XYZ> lobes, skin pink/warm/dry, -HEENT --- pupils PERRL, -TD/JVD, -CP, -abd pain, hips/spine/extremities stable, vitals stated.
TREATMENT: O2 at 15L/min via NRB. Pt stated some relief from O2 administration. Pt transported semi-fowler c continued evaluation.
DESTINATION: Pt to hospital <stretcher/triage> s incident. Pt care transferred to staff. END REPORT

Also supine sitting? Guessing ya meant semi-fowlers.

 

[Sasha]

upon arrival to scene 19 y/o male PT presents with a productive cough and states that "it hurts to breathe" PT states that "it all started when i was playing football with my friends" PT is seated in the tripod position, PT claims pain to be at level 5. upon questioning PT reveals that he has asthma. PT does not carry or have albutoral or any medication. B/P: 139/79 P: 70 R: 16 T:98. placed PT on NRB, and transported in supine, sitting position. continually monitored PTs breathing, coughing subsided during transport. conducted secondary assessment during transportation to hospital, turned over to medical officer

Here's how I would write it..

"Responded to XYZ code whatever per dispatch. Upon arrival our patient was a 19 y/o alert and oriented male found sitting, tripoded in a chair. Pt is c/o a productive cough and pain upon respiration. Pt states his pain is a 5/10 on a 1-10 scale, 10 being the worst. The pt states the pain began while he was playing football. The patient does have a history of asthma but is not currently on any medication. Physical assesment was unremarkable except for (whatever lung sound your little heart desires, crackles, rales, ronchi.) The patient stood and pivoted to the stretcher unassisted and was transported semi fowlers to hospital ZXY. En-Route the patient was placed on 10lpm of O2 via NRB. Upon reassesment the patient's coughing had subsided. At the hospital, the patient was sheet lifted to bed 4 and bed rails were put up, report was given to Nurse Nancy, RN."

Any report I've written has had a vitals section so it wasn't required in the narrative. That's where I put pulse, bp, O2 sat, temp, BGL, respirations, GCS.

Something I like to do with patient's c/o pain, is if I've done something for them I.E oxygen, when reassesing did the pain get reduced? Still the same? then document "Upon reassesment the patient's coughing had subsided but there was no change in pain level" or "upon reassesment the patient's coughing had subsided and his pain was reduced to a 2/10 on a 1-10 scale." or something.

Thats just my two cents. I'm sure some other, more experienced can help you a lot more!

 

[HNcorpsman]

wow i sure did miss alot... i do know all of this medical knowledge i just seem to have a difficult time remembering all of these things to write down... is there some kind of acronym better than SOAP to help me with these forms? i also would assume this is somewhat learned through experience aswell, right? as far as i understand the docs, and nurses dont even read the reports, so who is there to correct me? can someone list or mention the MAIN things that i MUST include in my narrative? i jsut need the MAIN things and i will learn more as i work... another thing that scares me a bit is that, the ambulance driver is a Japanese FF, who is not trained as extensively as i am. from what i have heard from the other EMTs is that they can not assist in certain procedures... will this be easy on me? also they will not send me to the hospital to work up my skills before they place me on the rig, i know. i already asked but thats how the military rolls. any advice?

 

[PapaBear434]

I usually use the CHART method.

C- Chief complaint: Includes how Pt. was found
H- History of chief complaint: Include other pertinent history
A- Assessment: Include "pertinent negatives"
R- Treatment (Rx): All treatment Rendered
T- Transport: Includes treatment rendered during transport

Some people use a straight narrative, writing it out in a conversational tone and more common phrasing. And others use nothing but a tremendous amount of medical jargon and acronyms that they don't teach in class, more along the lines of vquintessence's post.

Personally, I use the CHART method because I tend to be an extremely wordy guy, and if you let me I'd likely end up taking up three PPCR's trying to write out the entire incident. CHART forces me to keep it concise and to the point, though I shy away from too many medical abbreviations (like "neg." for "negative" instead of using the Ø symbol). Use descriptive terms like lateral or proximal at times, but I try to keep it fairly simple so that any layperson (or lawyer) looking at it can read it.

But that's all personal opinion. Everyone does it slightly different, and none of it is necessarily wrong. There are, of course, things that can be improved however. One I noticed is your pain scale simply says "5." Five out of what? Sure, we know it's PROBABLY out of ten, but your average layperson won't know and you better believe a lawyer would pick that out as an example of you being sloppy. Put down "Pt. reported pain to be at 5/10."

The biggest thing I can suggest is work on your "pertinent negatives." These confused the hell out of me when I first started doing reports. Basically, there are a set of things that you should list each and every time, even if the pt. condition has NOTHING to do with it. Basically, the list looks like this:

Head pain
Neck Pain
Back Pain
Nausea
Vomiting
Chest Pain
Difficulty Breathing
Abdominal pain/rigidity
Obvious discoloration, deformities, or other obvious trauma
Diarrhea
Diapharesis

Those have to be listed, or should be, at any given time no matter the case. So my "A" part of my CHART ends up looking like the following. Keep in mind, my vitals are listed in separate areas of the PPCR, so your mileage may vary:

Vitals taken as listed, pt. neg. head/neck/spine pain or injury, nausea, vomiting, ab. pain/regidity, diarrhea or diapharesis, no obvious trauma noted. Pt. pos. chest pain & brea diff, noted productive cough w/o wheezing.

Outside of that, something you REALLY want to look for in cases of chest pain and breathing difficulty is breath sounds. Really, you may want to include it in your pertinent negatives, but you don't ALWAYS check them. But in cases of chest pain and breathing issues, or with a history of COPD/Emphysema/Asthma/CHF, you probably want breath sounds to be one of the very first things you do. Listen to all four quadrants, note any wheezing/rhonci, and mark where you find it. I only say this because you didn't note it in your report. You may very well have listened to his lungs and noted they were clear, but without it being written down you can't prove it. If you don't write it down, it didn't happen.

Also, I suggest ending your report with "Pt. was transported to (fill in medical facility here) and turned over to ER nurse and staff. Pt was left in care of said staff with rails up." We had a guy almost get sued because he fell out of bed after a nurse lowered the rail to help him get in his gown, and forgot to put it back up. She then blamed the medic. If you say you got the pt. there without incident, and left him in the bed with rails up, your liability diminishes a lot.

 

[vquintessence]

... as far as i understand the docs, and nurses dont even read the reports, so who is there to correct me? can someone list or mention the MAIN things that i MUST include in my narrative? i jsut need the MAIN things and i will learn more as i work

Well I won't pretend to know how Japan runs its medical community, but I would assume your PCR is at least read by your superiors and any lawyer representing your pt should something happen.

The meat and potatoes you're asking for:
chief complaint and appropriate focused exam (ex: lung sounds and locating the pain your pt reported) including OPQRST.
vitals
interventions and response to intervention
physical exam (doesn't have to be hands on, the above one I wrote was essentially an eyeballing with asking pt questions to r/o pain in areas)
vitals

Like you said, you'll quickly learn exactly what's pertinent to put as ya go.

p.s. I think papa called me a nerd

 

[PapaBear434]

p.s. I think papa called me a nerd

I didn't mean it as offensive. Some people like doing it that way, with shorthand and symbols, and I would probably love it if they taught it in basic class. Get it as a universal. But as it's not universal language, and some symbols mean different things depending on where you go, I don't like them. Too many things for a lawyer to tear you apart on the simple basis that it ISN'T standard.

But that might be the time I spent in the police department talking. Everything you did on a report was designed to keep the defense attorney from getting the guy off on a technicality. Using non-standard acronyms was a good way to get him bounced because "...only YOU know what's written here, Officer. How do we know you aren't making it up as you go to fit the circumstances now?"

Looking at yours, for instance, I have to read it a couple times to infer what it means just because some of those symbols aren't used in my parts. You got all the info there, of course, and I can figure it out because I am in the same field. But your average slub? They don't know what the heck you're talking about.

Long story short: Yeah, I called you a nerd. Want to make something of it?

 

[vquintessence]

I didn't mean it as offensive. Long story short: Yeah, I called you a nerd. Want to make something of it?

Heh, was joking with ya. Glad we're on the same page

 

[HNcorpsman]

thanks for everyones help.

 

[Sasha]

Also, something that helped me write my reports adequately is finding a lawyer friend, write one, and have them find loopholes. Then fill in those loopholes. And keep on 'til you're writing iron clad soaps.

 

[Aidey]

CHEAT is another good charting method.

C - Chief complaint (Unit 123 dispatched Code x to 456 Main for a 19 year old male c/o difficulty breathing)

Hx - History - History of present Illness -HPI (the SLE of SAMPLE)
Past Medical History - PMHx (the AMP of SAMPLE)

E - Exam - Physical exam, OPQRST, Pertinent negatives etc

A - Assessment - Your differential diagnosis, the condition you have assessed the patient to have.

T - Treatment/Transport

 

[Aidey]

If you agency requires you to use SOAP, here is an easy way to help remember how to do it using the CHEAT acronym.

S < C & H
O < E
A < A
P < T

 

[AJ Hidell]

But that might be the time I spent in the police department talking. Everything you did on a report was designed to keep the defense attorney from getting the guy off on a technicality.

Excellent point. And that is one of the key reasons that we find that police officers tend to make much better medics than firemen do. They are detail oriented and already have a culture of meticulous documentation impressed upon them. It is very hard to pound that into the average fireman's thick head.

i am going to write a sample narrative document and i would like some insight on what you all think... i will be using the standard for military sick call at least SOAP note form...

Do you have a sample of that form for us? The form we used in the naval hospitals in Iraq is all I am familiar with, and it isn't really SOAP, nor is it appropriate for field use. Is it handwritten, or will you be entering this into a computer? Are there a lot of blanks to fill in with vitals and such, and a lot of boxes to check, or is it just a big blank page for a freestyle narrative?

If you are going to use SOAP, then use SOAP. You did not in the example you wrote here. Although there was a lot of missing info, here is a revision of your narrative in SOAP format:

S - Pt. states he was playing football with friends [how long?] when he spontaneously began experiencing pain on inspiration [opqrst?] and a productive cough. Denies trauma [?]. Admits hx asthma [detailed hx, incl. onset of disease, hospitalizations, previous meds] without current medication use.

O - 19 y/o male [you don't have to specify "PT". If you are charting about him, we know he is a pt.] presents sitting [on what?] in tripod position. He is [level of alertness] and [level of orientation, using specific criteria, not a number like 3 or 4], and [general appearance, incl. anxiety level, level of exhaustion, and respiratory effort]. V/S: BP = 139/79 [right or left?], P = 70 [quality and where taken], R = 16 [effort, pattern, depth], T = 98.0 [how taken], Sp02 = ?

HEENT: [general appearance? perioral cyanosis? trauma?, pupils? ear or nasal discharge?] Pt. producing a [description of appearance and quantity] sputum with a [quality and frequency] cough.

CHEST: [atraumatic? symmetrical? barrel chested? accessory mm usage? retractions? auscultation results in all five lobes? anterior or posterior auscultation?] EKG shows [?]

ABDOMEN: [flat or distended? movement with respiratory effort?]

EXTREMITIES: [strength and coordination of movement and ambulation. carpal or pedal spasms indicating hyperventilation? capillary refill time? nail bed color? edema?]

INTEGUMENTARY: [warm, hot, or cool? general and localized color? dry, moist, or diaphoretic? clammy? turgor?]

A - Acute respiratory distress, r/o asthma [vs. hyperventilation?]

P - O2 via NRB @ [? LPM]. Pt [ambulated or carried?] to [cot, captains chair, or squad bench?] where he was secured by [seat belts or straps?] in the [supine, semi-Fowlers, full upright, tripod?] position and transported via ambulance to [facility], and released to [last name and rank of nurse or medical officer]. Pt states [any relief or worsening of sx, or any new sx experienced]. A decrease in coughing frequency was noted during transport, and [any other changes or observations noted, as well as lack of changes].​

Just like in posts here on a forum, paragraphs are your friend. Narrative does not mean that you have to cram everything into one long paragraph. Break it up so that the reader can quickly and easily locate any relevant portion of the chart.

Good luck with your new assignment, Bro! This is a good thing for your professional development! Just remember, medicine is medicine. Very little should change from your hospital practice to your field practice. If it does, then you are doing something wrong.

 

[HNcorpsman]

the run form is just like any other form... it has blocks for all vitals and other pertinent things.. and it just has a standard narrative section for the EMT to write... so no, it does not have to be in SOAP form, i also think that SOAP is somewhat inappropriate for the narrative section... so i probably will use chart or cheat... so i kind of misunderstood your comment, did you say that i should write all my info in a paragraph? or that i should split everything up?

 

[AJ Hidell]

i also think that SOAP is somewhat inappropriate for the narrative section... so i probably will use chart or cheat...

Use whatever your medical facility is using. The report you are writing is for them, not for you. Therefore, it should be in a format that is readily understood by them. The people who need to read it are physicians and nurses, not other EMTs. This is another example of people thinking that the field should be different from the hospital. It is not. Keep things standardized to prevent misunderstandings.

so i kind of misunderstood your comment, did you say that i should write all my info in a paragraph? or that i should split everything up?

Sorry for being unclear. Everything should be broken into relevant sections, whether that is SOAP, CHART, or whatever. Remember, SOAP is not just a mnemonic to remind you what to put into your narrative. It is a method of organization. Organization is the key not only to keeping your chart readable, but for keeping your thoughts in a logical line of thinking that assures that you don't forget anything. If you lay things out in a SOAP organization, you can easily proofread it and look for missing items. If it's all crammed into one paragraph, you are going to forget things, not catch them on proofreading, and never even realize your mistake.

 

[AZFF/EMT]

Do you guys use standard charts or just write down narratives. Like everyone else said include pertinent finding and negatives.
Our charts go like this

Name DOB SS#
Past medical History/Conditions (CHF, Cardiac, Cancer, COPD ect,)
Allergies-Food, drugs, ,ect
RX's and OTC meds
Doctor's Name if applicable
Then we have a place for 4 sets of complete vital signs
Then Chief complaint
Then a space to write a narrative( Who you are, why you were called, what you found upon arrival, patients general apperance, what you initially did and then what you are going to do and where you are going)
Then spaces for your physical exam finding.......

Start with

Is the patient Alert-Awake and to Person-Place-time-events
Then pain scale 1-10

Compete a physical exam/interview in the OPQRST-SAMPLE methodI
Head/Face-
Neck-
Chest/Lungs-
Abdomen-
Pelvis-
Extremeties-
Back-

Then There is a place for:
hospital contacted (CN/Patch and RN/DR's name)
Orders given
IV solution and info
C-spine information if used
Thebn a little space for treatments rendered( 0.4mg Nitro SL pain down 4/10

I will try to upload a copy of our run report. Basically if you follow the run report and work on you narrative you will be fine, just be thorough on your exams and paint a good picture of what you saw and what you did.

 

[Aidey]

so i kind of misunderstood your comment, did you say that i should write all my info in a paragraph? or that i should split everything up?

In my opinion, break it up. Make it easy to locate info. For example with a physical exam don't cram it all together like this


AOx4. heent normal, airway open, no cyanosis. eyes perla. Chest is atraumatic. lungs clear with equal breath sounds in all fields. heart sounds S1 and S2 present. no clicks, rubs or murmurs noted.


It should be spaced out like this

LOC: AOx4

HEENT: Atuaumatic. Airway open. No cyanosis noted around the mouth.

Eyes: PERLA

Chest: Atraumatic. Lungs clear and equal breath in all fields. Heart sounds S1 and S2 present. No clicks, rubs or murmurs noted.

This way when someone is reading your report they can quickly locate the section they want without having the scan through the whole thing.

 

[Epi-do]

And then, for one more option, I write my reports in a chronological order so it reads like a story. I include everything everyone else has mentioned above, but rather that using CHART, SOAP, or CHEAT, I simply tell the story of the run.

Whichever method you decide to use is really just personal preference. Just get in the habit of always using the same format for every report you write. That way, you will develop a flow to your narratives, and including all of the information will become second nature to you. Sure, because every patient is different, the content is going to vary from narrative to narrative, but the format should always be the same.

 

[Aidey]

Keeping the same format is really important so when it's 3am and you just got done with some insane call you aren't drawing a blank on how to write your report.