need help with documentation

Good point, Aidey. And the real secret to the ability to write a good report is the knowledge and ability to do a good exam. The better your assessment skills are, the better your reports will be. While your exams should generally follow the same pattern, each and every time, so should your exams. So just review your exam in your head, put it on paper, and break it into sections, just like the exam itself, and you'll be good to go.

If you consistently write SOAPs in a manner similar to what I posted above, I can almost guarantee you that your name is going to be prominent among the Chiefs, MOs, and Nurses in your organization when it comes time to hand out commendations, choice assignments and promotions.
 
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Even if you don't use SOAP, and use CHART/CHEAT instead, good documentation catches peoples attention and will get you places as AJ said.

I personally have always used CHART, and I once received the highest documentation praise that exists, a Lawyer said it was a good report! ^_^
 
If I were you, Id stick to the CHART/S. So so so simple, cut and dry, and to the point without leaving anything out.
 
CHART/S ???

another question... do you guys write your reports as you care for the PT? or do you start writing when PT Tx is done and you are transporting to the hosp?
 
i just read the run report we use here in okinawa i will read it to you...
(these are all the boxes)

c/c
PMH
MEDICATIONS
ALLERGIES
AIRWAY- patent, compromised
BREATHING- clear, absent, shallow, labored, wheezes, congested,
CIRCULATION- strong, weak, absent, crt_____
DISABILITY- A&Ox____ verbal, painful, unresponsive
GCS- E______ v_____ M______
PREGNANT- no, yes, G____ P_____ AB_____
DETAILED PHYSICAL EXAM-
HEAD- no trauma, PERRL
NECK- no JVD, NTTP (what is this???)
CHEST- chest exp.
LUNG SOUNDS- bbs,
BACK- NTTP
SKIN- hot, warm, cool, dry, jaundice, cyanotic, diaphoretic, pink
ABDOMEN- soft NTTP
EXTREMITIES- full ROMx4
NUERO- upper + - lower + -
TRANSPORT- c-spine, POC, supine, prone, lateral, l, r, head elev, feet elev
EMT NARRATIVE
CPR- 1 man, 2 man.

it also has a Treatment box which includes

BP, TEMP, HR, RESP, SPO2, ACCU (?),
OXYGEN VIA, NC, NRB, BVM, NEB@ LPM____
GAG- y, n, OPA, NPA, COMBI-TUBE
FLUID- lr, ns, D5W
RATE- kvo, bol


so my questions is if my run report has all of these boxes, theoretically i should even have to mention them in my narrative correct? not to mention the EMT narrative is extremely small. cant imagine putting some of the things yall wrote down in that little section...

thnaks
 
NTTP = non-tender to palpation

I was afraid of your form being like that. The DOD ER forms are just about as bad. Lots of boxes to check, with little room for real documentation. It's dumbed down to the lowest common denominator, which is the lazy, ignorant, and illiterate among us.

You just have to adapt to it. Don't let the lack of a space keep you from documenting pertinent findings. Find a place for them. If there is a continuation sheet that can be used, don't hesitate to use it. And keep in mind that this may not be how your next civilian employer wants you to do things. And it is certainly not how your paramedic instructors will want you to do it. So try not to let this become such a solidly ingrained habit with you that you have trouble adapting to SOAPs when you get out of the Navy.
 
HNcorpsman said:
CHART/S ???

another question... do you guys write your reports as you care for the PT? or do you start writing when PT Tx is done and you are transporting to the hosp?
Click to expand...

I write down the basics. Patient name, birthday, SS#, address, vitals, maybe check a few boxes... But the actual narrative waits until the hospital. My handwriting is terrible enough without bumping down the road doing it.

We are suppose to go to a computerized system here sometime in the next year or so. I can't wait. I can type SO much faster than I can write, and the handwriting won't be an issue anymore.
 
so basically these forms have everything for a check box, like the detailed phys exam... instead of writing wheezing, you would check the box...

i dont know i think its quick and to the point form... that way the nurse or MO can just glance at the run report and see what he needs to know instead of reading...
 
I dont really right anything but the vitals down.

I do my paperwork after the pt has been delivered.

Just paint the picture. You will devise your own style as you go.
 
PapaBear434 said:
We are suppose to go to a computerized system here sometime in the next year or so. I can't wait. I can type SO much faster than I can write, and the handwriting won't be an issue anymore.
Click to expand...

We currently use E-PCRs. Don't expect the typing to be any easier on a bumpy road. The keyboards are very small and cramped. But, there are alot of dropdown boxes with our program. And, they have script recognition where you can write in a box with the stylet. That takes some practice, but it usually recognizes words for what they are. The PCRs take twice as long tho. But, not much info is missed.
 
Yeah, doing it on the road is almost completely out of the question, especially in a type I ambulance. They ride rough as heck. On a military base, your transports aren't going to be long enough to write much anyhow. And most of all, you need to be devoting your undivided attention to your patient. EMS isn't like IFT, where you often have a gorked patient that requires no social interaction. So just save it til you get to the hospital. I even save entering vitals until I arrive at the hospital to avoid screwing up the form with sloppy writing while riding.

If you enter something in a box, then there is no real reason to enter it again into the narrative. I suppose you are going to have to reserve that area for specific details that don't fit into the boxes. I would definitely do two things:

1. Ask your Chief what he expects in the way of documentation. His idea of good may be completely different from ours. You just never know, and what he expects is what you should be doing.

2. Review the run sheets of other providers to see what the "norm" seems to be. Just bear in mind that not all those guys may be doing it right. But at least you can see what the prevailing culture is there. But if the prevailing culture is teh FAIL, you'll want to discuss your ideas for improvement with the Chief.
 
RESQ_5_1 said:
We currently use E-PCRs. Don't expect the typing to be any easier on a bumpy road. The keyboards are very small and cramped. But, there are alot of dropdown boxes with our program. And, they have script recognition where you can write in a box with the stylet. That takes some practice, but it usually recognizes words for what they are. The PCRs take twice as long tho. But, not much info is missed.
Click to expand...

The ones our neighbor city uses (we share a couple hospitals) just detach from the base and can be brought in to a docking station inside the Rescue room. THAT'S what I want.

Our computers are the very same computers, but we don't have docking stations to fit them nor do we actually have a system set up to take Pt information. We just use ours to communicate with dispatch and not tie up the radio.
 
actually, i am gonna be either at camp hansen or camp schwab... hansen is about 30 mins from the naval hospital, schwab is about 45 mins...

but your right i probably should just play it safe and wait till i get to the hospital.
 
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