Notetaking during a call

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drCHEMcee

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I'm sure this topic has been discussed but what are the best ways to take notes on a call? I've heard and seen the usual suspects glove, dfib paper, notepad, pillowcase lol; any others?
 
Do not write on your glove. It is stupid. Glove gets soiled....your notes go bye bye. Additionally ink often smears or if it gets wet, again, note go bye bye.

A simple notepad will suffice. If that is not cool enough then a strip of 2 inch tape on the leg works great. When squatting or sitting as we often find ourselves, you are in perfect position to document. Again, tape on leg has equal opportunity to become soiled, but not as high risk as a glove in my opinion.

Stick to note pad.
 
It looks incredibly stupid and cheesy but I write on a piece of medical tape stuck to my leg. 2-3" of the 2" tape makes a nice notepad that's stuck to your leg so you won't lose it like a paper notepad and it won't get it torn or thrown away like a glove.
 
I have a bunch of index cards held together by a small clip. I use that. If I need to hand it off to someone like the medics (or my partner if they're driving and need to make the entry note for some reason), I can just take the notes off and hand it to them. Works very well. If you want, you can also put them through a printer and print stuff on them to customize them (nerdy? Hell yes! But it works!). For example, I made a table for places to put vitals, name, etc.

If worst comes to worst and I forget my notepad in the front of the ambulance, I can grab a 4x4 and write on the back of that.
 
I just write on a notepad, usually times and quoting the patient.
 
Top-spiral note pads. Cheap at Staples.
Use a "clicker" pen, not a capped pen you stick in your mouth to pull the cap off. Ick.:wacko:
 
mycrofft said:
Top-spiral note pads. Cheap at Staples.
Use a "clicker" pen, not a capped pen you stick in your mouth to pull the cap off. Ick.:wacko:
Click to expand...

That's gnarly and unprofessional, I'd smack someone if I see them talking to a patient with a pen cap in their mouth. Or using their mouth to pull the cap off. I keep extra pens on hand in case a patient with bodily fluids all over, or is has a poor hygiene habit needs to sign. I just let them keep it. I got more.

I use 3x5 index cards, these things cost like a buck at your local dollar store for meh 100 minimum. You can get ambitious and get pretty color ones too. I use one side of the card for Incident location times mileages and pertinent patient information. Demographics and the such. The other side gets my Complaint, Assessment, Meds/allergies, Hx. and treatment plan. When Im back at station charting it doesn't look like a bomb went off I got each index card for my notes
 
What I use for note taking on calls simply depends upon the type of call and how much I expect to work during that call. Most calls, I'll use a notepad. They're cheap and work well. If I'm going to be busy, then I'll put a 2" x 14" strip of tape on my leg and take notes on that. If that tape gets soiled, so has my uniform.
 
I don't take notes. Period. I write my chart on the proper PCR or ePCR software.

I have, however, rewritten my chart completely once I made it to the hospital, but I don't do that note writing thing on gloves, tape or pads. I use my documention to document what i need.

Then again, I work in a 2 man crew; one charts while the other assesses and treats. even on a sick calls, get your vitals and medicatiosn and history, and write your chart on the way to the ER. and on those sick calls, you usually have someone with a spare hand who can play scribe, and we all copy in the ER
 
I'm like dr parasite, but on the rare occasion I need to write on paper (usually a train wreck situation) I write on monitor paper.

My partners joke that that's how they know I'm giving out my phone number or email address or the bomb has gone off. If I'm writing on paper, it's on.
 
DEmedic said:
Fire captain.
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That's how it is here. You want to know who the fire captain is on the scene of a medical call? Just look for the firefighter writing on paper or the computer.

A lot of people bag on us for having fire respond on medical calls. Yes most of the time it is not needed but it's always nice having the fire guys grad our gear and document on scene for us.
 
DesertEMT66 said:
That's how it is here. You want to know who the fire captain is on the scene of a medical call? Just look for the firefighter writing on paper or the computer.

A lot of people bag on us for having fire respond on medical calls. Yes most of the time it is not needed but it's always nice having the fire guys grad our gear and document on scene for us.
Click to expand...

Oh yes. You feel all badass as a medic, knowing it's just you and your partner against the world, with help 15 minutes away *if* it's coming.

And then sometimes you have someone to help schlepp all your stuff and carry the patient to the truck while you ponder your plan of care and discuss things with the wife. And then you think maybe that whole fire plan is maybe a good one.
 
I'll give you a real reply on how we work a call.

We run a dual Medic truck and we do 24 hour shifts. The first 12 hours of the shift one Medic rides officer and the other Medic drives. The "Officer" is in charge of the patient interview and he will end up talking to the Doc, writing the report etc. etc. The "driver" Medic is responsible for hunting and gathering. He or she will get info from the fire crew, find meds and also interview any friends or family members, clinic or SNF staff present during the call. By the time the officer has completed patient exam the two will meet to talk over the next move. We do it the same way every run and we are charting on a run sheet on a clipboard. The Medic "driver" is also known as the skills person. Any lines or tubes are done by the driver and then we swap spots half way through the shift. On a CPR or any critical patient that needs ALS care quickly we will hand the clipboard to a firefighter and go to work. Officer does the line, driver gets the tube :beerchug:
 
I've always wrote in a small notebook and if its clean after a run I put it in my back pocket until the next call
 
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