Patient Reporting...What do you do?

[Craig Alan Evans]

I developed this method of writing patient reporting years ago after I was tired of SOAPing and all the other mnemonic methods that didn't seem to have a good logical order to me. Feel free to use this as you see fit, change it, pass it on, help out our fellow providers. I also use this broad outline when giving verbal reports over the phone.

D: Demographics
Age, Gender
C: Chief Complaint
What are they complaining of? Not to be confused with what do you think is wrong with them.
H: Patient History
Pertinent past medical history, surgeries, medications, allergies
E: Events leading up to the 911 call
What happened just before they called for help that contributed to the emergency
A: Assessment
Your physical assessment findings
B/P, Pulse, Respirations, O2 SAT, Blood Glucose, EKG, 12-Lead, Lactate, and whatever other numbers are pertinent to the patients emergency.
T: Treatment
What did you do for the patient?
R: Response to treatment
How did the patient respond to your treatment plan?

 

[JPINFV]

What do I do?

Well, day in/day out it's just pure SOAP now, but different location, different needs.

If I went back to the field, I'd use an adaptation of SOAP that I designed that I call Pre-SOAPeD.

http://emtmedicalstudent.wordpress.com/2011/01/20/ems-documentation-introducing-pre-soaped/

 

[Craig Alan Evans]

Jpinfv

Nice Blog!

 

[Aidey]

Congrats, you discovered CHART, lol.

CC
HX - HPI, past hx etc.
A - Assessment
R - Rendered care which is treatment
T - Transport

 

[Craig Alan Evans]

Yeah, I know it's a version of CHART..lol No use reinventing the wheel.

 

[Rettsani]

why are you trying to reinvent the wheel, when you know that there is no use reinventing the wheel? :unsure: you"re Questions confused me.....

 

[Craig Alan Evans]

Just didn't like CHART. Nothing personal against CHART.

 

[abckidsmom]

I like CHART. I think it is the simplest template that covers the most ground and I never forget a piece of the puzzle at 0330. I have a standard head to toe assessment blurb I used to use before our PPCR software included a check box physical assessment that autopopulates in the A section of my narrative.

Having used CHART thousands of times I can teach it to anyone in my sleep and explain the reason for each part and potential nuggets that students need to include without any thought or prep at all. Since I have absolutely fresh newbie EMT preceptees all the time this is key, because the one shift with me might be the only time they see The Only Right Way to do EMS and I want to make it stick.