Our ePCR software has a lot of drop down menus and bubbles that are used to generate a narrative that we then add subjective information into it. All my treatments and what not are in a flow chart that's imported into that narrative when I generate it. When it's all said and done our charts look something like this. There are a lot more random proprietary things that it adds that I can't remember and don't care to type but I'll get you an example.
Upon arrival we find a 65 year old male PT laying supine on the floor of the bathroom inside the home at the above noted address in obvious severe pain with FD personnel already on scene. PT is A&Ox4 with a GCS of 15 and complains of 10/10 left hip pain. The pt states he was getting out of the shower when he "slipped and fell on the wet floor" and landed on his left hip. He states he felt a "pop" when he hit the ground and had an immediate onset of severe "sharp, stabbing" pain which he rates at a 10/10. The pain is exacerbated by any palpitation or manipulation of the patient and is not relieved by anything. The pt states he would like to be transported to XXMC for further evaluation and treatment. The pt denies any recent illness or medication changes, LOC, head/neck/back pain, chest pain, palpitations, shortness of breath, abdominal pain, numbness/tingling or any other associated complaints before or after the fall. An IV is established and the PT is premedicated with IV fentanly and versed. The pt's bloomsbury sedation scale (BSS) is reduced to a -2 and the pt is scooped onto a scoop stretcher and carried to the gurney where he is placed supine and the scoop stretcher is removed. The pt is moved to the ambulance where his BSS progressively improves to a 2. The pt now states his pain is a 5/10. The pt is transported to xxMC with the changes noted below en route. The pt is lifted from EMS gurney to XXMC ER bed with the assistance of ER staff and a slide board and Pt care is transferred to ER RN.
Changes en route to hospital:
Pt complains of "spikes" in his pain secondary to bumps in the road. He now rates his pain a 8/10. Pt is remedicated with fentanyl and states his pain has been reduced to 4/10, BSS reduced to a 0. Upon arrival to XXMC BSS +1. No further changes in assessment or pt complaint during transport.
Physical assessment: (This is a drop down attached to a flow chart selection that is imported into the final copy of the chart
Head: PERRL at 4mm, no JVD, trachea midline, no signs of trauma, no drainage, no crepitus or step-offs noted during palpation of C-spine
Chest: No signs of trauma, equal rise and fall, CTAB, no sub-q air or crepitus noted
Abdomen: Soft, non tender, no signs of trauma, no palpable or pulsating masses noted, no discoloration.
Pelvis: Stable, deformity to left hip noted, no incontinence.
Extremities: Shortening and external rotation of left lower extremity, crepitus noted in proximal thigh, +CMS. All other extremities unremarkable.
Back: No signs of trauma, no crepitus or stepoffs noted or pain reported during palpation.
Neurological Awake, Initial GCS, Final GCS, Pupils
Respiratory: Breathing rate and quality, lung sounds
Cardiovascular: Skin signs, presenting rhythm and rhythm upon arrival to ER, cap refill
Flow chart:
PTA Pulse oximetry
PTA Nasal Cannula Oxygen 2.0 LPM inhalation
22:00 ALS Assessment
22:00 Urgent Care Assessment - Not appropriate for Alternate Destination - requires IV analgesia, possible complex fracture/dislocation requiring surgical intervention.
22:01 Comfort and Re-assurance
22:02 Explanations to Patient provided
22:02 IV 1st, right forearm, 20g, 1000cc bag of NS TKO
22:03 ECG Monitor
22:03 ECG Interpretation Sinus rhythm without ectopy
22:03 BSS Assessed +3
22:03 Zofran 4.0 MG Intravenous
22:03 Versed Bolus 1.0 MG Intravenous
22:04 Fentanyl Bolus 100.0 MCG Intravenous
22:06 Re-assessment - BSS reduced to -2, pt placed on scoop stretcher and moved to gurney.
22:08 Seatbelts applied
22:10 Re-assessment BSS now +2, Pt complains of exacerbation of pain secondary to bumps in the road, rates 8/10.
22:11 Fentanyl Bolus 100.0 MCG Intravenous
22:15 Re-assessment Pt states pain reduced to 4/10m BSS reduced to 0
22:20 Re-assessment BSS now +1. No other changes from previous re-assessment upon arrival to XXMC
22:20 Total Fluids In 0.9% NS 150 ML Intravenous
Vitals would be put in in a drop down menu and imported. Same with history, allergies and medications
This is a real basic look at what they look like. Our charts are generally about 3 pages printed if its BLS or ILS. ALS with ECGs attached can easily be 5+
Our transfer charts generally look like this. I wont do the exam and what not just hte narrative part.
Upon arrival we find xx year old pt laying in bed at xx ER. Pt presented to ER at xx time complaining of xxx. Pt was diagnosed with xxx and is being transferred to xx hospital for xxx services which are note available at the sending facility. The pt was premedicated by staff PTA of EMS and denies any acute complaint. Pt is lifted onto EMS gurney, placed in poc, moved to the ambulance and transported to xx facility without (or with) changes. pt is lifted from EMS gurney to XX MC bed and Pt care is transferred to XXMC RN.
