Patient Narratives

[NPO]

> Response info

> What I found
> What I found after a better look

> What I did about

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[NomadicMedic]

> Response info

> What I found
> What I found after a better look

> What I did about

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Very funny. Mine is similar now.

Response info.

What they told me.

What I saw.

What I did.

 

[dutemplar]

They're pushing the APs towards an IMIST-AMBO for turnover reports and where narratives are still used.

Completely irrelevant, but something I recall seeing years ago:
You didn't have a narrative. You submitted a large, awkward, random assemblage of sentences. If true, the sentences were kidnapped in the dead of night and forces into this violent and arbitrary plan of yours clearly against their will. Reading your narrative was like watching unfamiliar, uncomfortable people interact at a cocktail party that no one wanted to attend in the first place. You didn't submit a narrative. You submitted a hostage situation.

 

[Ewok Jerky]

SOAP

S: what the patient tells you.
O: objective findings including what you see and smell, the scene, vitals, physical exam, moniter.
A: 1 sentence summary
P: your treatment including intervention and transport decision.

 

[Hold My Beer]

Ask your QI/QA what method they prefer. I always used SOAP back when I still used paper reports. I loved chronological but my QA/QI department has since forced SOAP on us. Lame.

 

[NomadicMedic]

Ask your QI/QA what method they prefer. I always used SOAP back when I still used paper reports. I loved chronological but my QA/QI department has since forced SOAP on us. Lame.

I could never understand why people got bent out of shape over things like the documentation standard. It's how they want it done. And really, who cares?

If it helps QI get through the charts and helps billing increase the reimbursement, I'll write em any damn way you want.

 

[EpiEMS]

I'll write it any way they want...they just have to tell me how they want it written. Took me a while to get my agency's standards down...because nobody has written them down clearly.


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[StCEMT]

I could never understand why people got bent out of shape over things like the documentation standard. It's how they want it done. And really, who cares?

If it helps QI get through the charts and helps billing increase the reimbursement, I'll write em any damn way you want.

Probably annoyance. I don't particularly care, but it is going to take me a bit to make sure I remember all the bullet points of DACHARTE after having been writing chronological.

 

[planetmike]

Probably annoyance. I don't particularly care, but it is going to take me a bit to make sure I remember all the bullet points of DACHARTE after having been writing chronological.

What is the first A in DACHARTE?

 

[StCEMT]

What is the first A in DACHARTE?

Arrival. What you saw, pt location, other units on scene etc

 

[Harleyjon]

What I do is kind of SOAP and kind of Chonological. Dispatched to, on arrival found, bystanders and Pt stated, T/P requested, Hx, meds, allergies, Tx: vitals, interventions/responses, report called in/ any orders, Pt conditon/changes during T/P, arrival at ED. When I started I formed my own system and I would read all the reports I could get hold of and slowly tweaked it here and there as I went along. The one thing I have done is try to write every report the same way as I have been going along. By doing this I find it easier to make sure I have not forgotten anything. So far this has worked for me.

 

[DrParasite]

If you ask 10 EMS workers what the best charting method is, you will probably get more than 10 different answer. Throwing in QA/QI, billing, your FTO, your medical director, paper vs electronic, state requirements, and you can see where it all goes to ****....

DrP's rules for charting: 1) if your agency has a specific way they want to chart, and everyone follows the same method, than that is the way you write your chart. If your agency says one thing, and someone else say otherwise, (FTO, billing, etc), than they need to have a chat so you are all on the same page, and get back to you on how the "agency" wants it done, and then the agency needs to then make sure that everyone is on the same page.

2) paper charting and electronic charting are done different. the content might be the same (and should be), but the method of charting is different. in some electronic charting systems, you shouldn't have a traditional narrative.

3) If no requirements are provided (and no, my FTO's opinion doesn't count) I do chronological, for the simple reason of it's how my brain works, and if I get called into court / medical review / medical directors office / supervisor's office over something, I have my documentation the way I want it, complete, and easy to review.

Day 3 of paramedic school, the local county EMS deputy director was giving a lecture on documentation, going over charte, soap and another one that I can't remember. then she gave a demonstration of a scenario, and the students were supposed to document what happened. when she asked us to give our narratives, I gave mine, using my chronological flow, entirely from memory, because that's how my brain likes to record things.

It's not rocket science, but it does take practice, and repetition is the best way to accomplish it.