Patient Narrative Help

renejr818

renejr818

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I just started my first day of training as an EMT-B. It is a private, BLS-only transport company so it seems that we mostly do IFT. With that said, I am using this as a stepping stone before I try to get 911 experience.

With the background out of the way, I was hoping someone could help me out with abbreviations and common methods of writing patient narratives for an IFT company.

My first day was mostly me shadowing the FTO and his driver. In the following days of training, one thing I will do is start training on writing paperwork. I know every company may vary slightly, but I would like to get a head start by learning common practices as well as hopefully getting a list of approved abbreviations if possible.

I appreciate anyone that helps and thank you in advance.

p.s.

I am within the LA County Scope of Practice, if that makes a difference.
 
While I can't speak specifically to LA County approved abbreviations, I will say this about your narrative: it should paint a picture of your patient. Describe your patient from head to toe in a way that hopefully doesn't double chart things too much. You wan the person reading your report to "see" what you observed and through that, understand why that patient had to be transported.

One more thing: Never lie on your reports. While my paychecks did come from good billing, they also came from my company not having to pay out fines for fraud.

If spelling is an issue, carry (at least on your ambulance) a medical dictionary, if not an app on your smart phone (if you have one) that will help with spelling. While people generally aren't fantastic at spelling, at least get the medical terms right.
 
Stay off abbreviations at first, and moderate them later.

Avoid conclusions. I.E., don't write "congestive heat failure" or "CHF", write vital signs and any other notable factors like rales, rhoncii, swollen ankles.If the pt is a simple transfer, maybe just record vitals and pt statement of condition (states feels "fine", walks to wheel chair). Ask your preceptor about that.

Quotes are good. So are times (on scene, with pt, depart with pt, relinquish pt & to whom.

And avoid the deadly "WNL" ("within normal limits").
 
mycrofft said:
Stay off abbreviations at first, and moderate them later.

Avoid conclusions. I.E., don't write "congestive heat failure" or "CHF", write vital signs and any other notable factors like rales, rhoncii, swollen ankles.If the pt is a simple transfer, maybe just record vitals and pt statement of condition (states feels "fine", walks to wheel chair). Ask your preceptor about that.

Quotes are good. So are times (on scene, with pt, depart with pt, relinquish pt & to whom.

And avoid the deadly "WNL" ("within normal limits").
Click to expand...
Not only does "WNL" mean "within normal limits" it can also be understood to be "we never looked." Remember, while "normal limits" may be defined by someone, somewhere for the purposes of documentation, the patient always defines their own limits and rarely tells you what they are. If I'm charting vitals in my narrative, I may write "within expected limits" but I always make sure to chart the vital signs and I always reference the source for where I obtained that information. Otherwise, nothing is "WNL" and I document accordingly.
 
If we use WNL we have to import this section of definitions of WNL to our narrative.

Takes less time for me to just right out my assessment findings and things that aren't pertinent get "unremarkable" if I looked and didn't find anything or "not visualized" if I didn't look.
 
As others have stated, stay away from abbreviations. Especially with epcrs now there is no real need for them and they can cause more confusion than they are worth.

I usually structured my IFT notes by where are we picking up from (house, SNF, dialysis), who requested us, and reason for transport. Then I mention where I found the patient (wheelchair, sitting on couch, lying in bed). Usual SOAP format follows. Subjective- what you see and hear. Objective- what you measure and test. Assessment- what you think is wrong. Plan- what you are going to do. Make sure to include how the patient transferred to/from your gurney and why they have to go by ambulance.
 
Staying a way from abbreviations is not an option. It's something my FTO emphasized that I need to learn and start doing on my next training day. I don't really want to debate, it just is what it is so I'd appreciate it if anyone can help.

:) Thanks, guys.
 
renejr818 said:
Staying a way from abbreviations is not an option. It's something my FTO emphasized that I need to learn and start doing on my next training day. I don't really want to debate, it just is what it is so I'd appreciate it if anyone can help.

:) Thanks, guys.
Click to expand...

make sure your FTO gives you a LST of APPD ABBs
 
If your FTO is demanding that you use abbreviations and write your naritave a specific way he is probably not a very good FTO. because you said you work for an all BLS company I am going to assume its a smaller, less legitimate outfit, as many are.

You do documentation your way, as long as its appropriate. Include all nessicary information, reason for transfer via ambulance at the level provided, reason for destination/transfer, and any treatments provided.

I also recommend learning SOAP. Even if you don't use it exactly it will give you an idea. I never learned it until 2 years as an EMT. I found that after my training dept helped me structure good naritives through coaching, I would up using SOAP anyway by the time I learned it.

LA County Approved Abbreviations for EMS: ems.dhs.lacounty.gov/ManualsProtocols/RFTM/RFTM-Abbreviations.pdf
 
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