Patient Narratives

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StretcherFetcher

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What formula or strategy do you all use to write your patient narratives? I'm starting my second week on the job and I'm struggling to find a consistent theme to use.

Any mnemonics ?

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I use a chronological order. So I describe the call as it played out. For me it flows better and makes a nice story.
 
Ask 20 different providers, you'll probably get 20 different answers......FWIW I personally like chronological narrative myself "Dispatched to this, found this patient in this way, complaining of X, Secondary to Y, History of Present Illness/what happened, Pertinent positives/negatives, History, Allergies meds (though those are listed elsewhere on our form so I'll usually only mention the HAM if it's directly pertinent to the CC and/or treatment), Treatments rendered, transported to A Hospital for B reason, any changes" is a basic flow....basically just tell the story of what happened.
 
I really like soap. Used it for years. Smells good. Duke Cannon is my friend.
 
PMHx/SHx/FHx as appropriate
HPI/CO
O/A
O/E
Impression/diagnosis
Plan

If it is decided to both refer somewhere AND transport there then "enroute" too.
 
In the past I have used primarily SOAP, CHARTED, and chronological methods of charting. What I've found is when your brain just doesn't want to work, chronological works quite well because you're basically retelling the story of your patient contact from start to finish. It is lengthy but easy to learn and use otherwise. When I do a SOAP (or SOAPIE) note, it's NOT like doing an H&P because the focus is on the story, my exam, etc. It's not exactly easy to learn but it works for me.

There are tons of other methods out there for charting but the one that simply sprains my brain (think result of a Chihuahua imaging the sound of one hand clapping) is PIE. This is Problem, Intervention, Evaluation. It skips a lot as it's basically charting by exception.

In my ED, we do Chart by Exception. While we do look at all systems, we FOCUS on the primary problem and go from there. CBE drives me nuts because to truly do this, if there's NOTHING wrong with the patient, your chart would be nearly blank. For the speed necessary in the ED, CBE is very much an advantage.

For one of my employers, they disliked me doing SOAPIE notes because I was pretty much the only one using it (our transport nurses did too, but they were special...) and the billers weren't used to seeing documentation done that way. They didn't stop me from using it though. That was back in the days of paper charting, so I had much flexibility in how I documented stuff.
 
I write chronologically/follow the call. Generally goes complaint > history > assessment > interventions w/ justification.
 
I actually write a chronological, in a modified SOAP. It's how our old software worked, and now it's how I write 'em without even thinking.

I rarely include any of the vitals or assessment points in the narrative, as they're all marked in the flow directly above my text block. Obviously if something changes or is of significance, I note it.

It's a little goofy, but I've been doing it that way for years and nobody ever complained.
 
I use a CHART in a chronological way. Ive done it since I started but it evolves regularly.

Were given the freedom to do what makes us feel comfortable. Our director tried to change us to timeline narratives in EMscharts cause thats what the precious flight crews do. He eventually gave up.


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I write an HPI-like format.

Pertinent dispatch info
HPI (history of the present illness)
meds, history, allergies, family history, social history

Review of Systems (General, Head/eyes/ears/nose, neck, cardiovascular, respiratory, abdomen, GI/GU, skin, neuro, psych, musculoskeletal)

Objective (Same as ROS but without psych)

Plan with all treatments, transport info, vitals, etc, done in chronological order
 
@Chase and @Akulahawk, do you find your charting methods influenced by your nursing education?


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EpiEMS said:
@Chase and @Akulahawk, do you find your charting methods influenced by your nursing education?


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Click to expand...
I haven't been in the field in quite a while. That being said, I wouldn't change my charting even though I'm a nurse. If anything, my nursing charting has been more influenced by my Paramedic education and experience...
 
I do the SOAP thing. Our software has a whole page for assessment that includes free text spacing for all systems, so I just say "See assessment tab of this ePCR." The plan is more of a chronological overview of the call, to include treatment (with justification and result), how the patient was moved, and what (if any) changes occurred during txp.

I hate the AMR Meds Objective section and don't really use it. Instead I write out a whole review of systems in the Objective portion of my note. ESO is much better.
 
Pertinent negatives help a lot with BLS reports, especially since usually there is a lot NOT wrong with them on BLS rides lol
"Denies pain in blank, blank, blank, etc". No SOB. No LOC. No n/v. Also it helps support that it's a BLS ride and not als.
 
Tigger said:
Meds is the PCR program, objective is just a tab.
Click to expand...

Ah, ok, gotcha. My lack of knowledge here is perks of not having worked for the 'evil empire', I guess ;)
 
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