Prehospital narrative template?

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cointosser13

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Does anybody have a prehospital narrative template where they just fill in the blanks or *** as they go along with the report (off course add more as they go along with the report)? If you have any templates that would be most appreciated. I'm trying to create my own as of now, but I want to get some ideas off other people.
 

Aprz

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I think a lot of have ways we write thing, like phrases, and orders that we write things. For example, I'll write something "The patient's face was symmetrical, no pronator arm drift, he spoke without slurring his speech, he denied diplopia, and he was able to do the finger to nose test for balance." when I do a stroke exam. The usual order I write things is the PHI first using SOAP, and the rest of the stuff chronological. I don't know how good it is, but that's how I do it.

Medic 42 responded code 3 to a home for a 59 year old male complaining of non radiating 7/10 sharp chest pain. The severity of the pain increased with palpation. The patient's symptoms started at 1 pm today while he was sitting down watching TV. The patient denied having dizziness, nausea, and shortness of breath. No deformity or contusion appreciated at the patient's chest. The patient's breath sounds were clear and equal bilaterally; No adventitious breath sounds appreciated. ECG and 12-lead done to look for possible cardiac arrhythmia or ischemia.The patient's ECG and 12-lead showed a sinus rhythm with no acute ST changes.

Upon our arrival, the patient was sitting on a chair inside of the kitchen being attended to by Antioch Fire Department Engine 10. The patient was alert and oriented to person, place, and time. He stood and pivot to the gurney. Loaded the patient into the ambulance. Transported code 2 to the closest hospital, Kaiser Antioch.

During transport, monitored the patient's vital signs and ECG. Established an IV for possible fluid or medication administration. The patient's condition did not change during transport.

At hospital, moved the patient to room 14 in the emergency department. The patient self scooted from the gurney to the bed. Oral report given and transferred care to the RN.

(for those who are familiar with the city I mentioned in here, I do not live or work there)

I feel like it is mostly fluff, but I like to paint a picture of what happened to the call, and I feel like that is the easiest way for me to do it.

Anyway, use SOAP, CHART, or write it in chronological order. You'll develop a style. There are a lot of example narratives online as well. It's kind of hard to use a "template" that is already prewritten for calls because you'll either leave out or a lot or end out having to add a lot. The problem is that patient's don't typically have just one symptom, and sometimes you have to go in a bit further for each one (it's not always as simple as OPQRST only). Plus they might have a story for you too to add.
 

Akulahawk

EMT-P/ED RN
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The easiest way to write a narrative is to write it in a chronological format. This, simply, is a record of events and findings as they unfold or are discovered. I have used CHARTED, SOAP, or a variant of one of these in the past. I do not "double chart" things in the narrative that are recorded elsewhere in the report unless it is absolutely necessary. As to a "template" that you can use to simply "plug in" things, as you write your reports, you'll do a couple of things: you will find your own style of charting and you'll also develop your own templates that you will use for various patients. A trauma template will be different than a stroke template which will be different than a chest pain template which will be different than a dialysis run template.

In the end, I want my reader to have as complete a "picture" of the patient I found and how things developed from there. Most importantly, I want to be able to use the document as my long-term memory because 7,000 patients later you will not likely recall that particular patient. Your documentation will be what saves your bacon or fries it...
 

planetmike

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It would be better if you create your own. If you're still learning, that will help you with both the short-term memory of the call, and with translating that memory into a coherent report that will be useful x number of years later when you get sued. Heck, I can't remember details of a call after two weeks, let alone 7,000 calls later.

I use a DCHARTE format. It is what works well for me right now. Others in my agency hate it and just do a chronologic report. Of course, I look at their report, and hate it as well. Use what works for you and your agency's QA/QI process.
 
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cointosser13

cointosser13

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The type of template I'm talking about is the "fill in the blanks" one. I already know about the SOAP/ DCHARTE method and what not, I'm talk about a template like... "Responded priority 1 for **. Patient is a ** y/o **". That type of template.
 

Aprz

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The type of template I'm talking about is the "fill in the blanks" one. I already know about the SOAP/ DCHARTE method and what not, I'm talk about a template like... "Responded priority 1 for **. Patient is a ** y/o **". That type of template.
Do people really do this though? I imagine that would be very difficult to work with.
 

DesertMedic66

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The only time I have ever used a template was when I was on a BLS unit doing only 5150/psych transports.

For ALS it would be hard to have a template that would be useful in anyway due to how varied the calls are.
 

luke_31

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I agree with DesertMedic66 asides from the we responded part to the narrative, a template isn't very useful for ALS calls. The only time I've ever used a template is on dialysis calls and even then I was still writing them.
 

Bullets

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I do chronological

What happened that caused EMS to be called, treatments provided prior to my arrival

How i observed the patient upon arrival

Movement to ambulance

Arrival at ER

I also do not double chart, so if there is a field elsewhere that notes something, i dont also put that in the narrative. So i usually dont have an assessment in my narrative, nor do i have vitals, meds or procedures i do. Example

Patient was at home working on his computer when he began having chest pain that radiated into his left arm and felt tingling in his left hand. Patient took 0,4mg NTG SL and called 911. EMS arrived to find the patient sitting in chair inside front door of his house. Patient was assessed and interviewed. Patient was assisted to cot and secured. Transported to St Farthest. Upon arrival report given to RN and signatures obtained. EMS was complete.
 

Kevinf

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Using an ePCR as it was intended to be used? Madness!

For quite a while, my first job had us triple charting. Fill in a full paper chart, complete an EMScharts EHR, and then pretty much duplicate everything we put on either chart into the ePCR "narrative" section. Of course, everything had to match perfectly, so if there were any discrepancies at all between your three charts you're getting flagged and need to fix it. True insanity at work.

It's better these days, we use ESO at both my transport and at my 911 agency. Still wind up putting a lot of stuff that's already been charted in the drop downs right back into the narrative though. At my transport agency, we have everything done electronically via tablet, including patient signatures. At my 911 agency, we still have a basic paper chart to complete, paper signatures to obtain, then a EHR chart + narrative... but most of the paper stuff is very basic so it's quite not as much of a pain in the *** as the first paragraph was.

I'm still waiting for EMS to haul it's collective *** out of the stone age.

edit: Almost forgot. Despite the author's name, provider level, and cert number being automatically added to EVERY SINGLE PAGE of the printed EHR, and despite the program logging who is signed in when something is edited/created, it's still required at BOTH agencies to put (Name, provider level, and cert number) at the end of the "narrative". I wonder why are we even using electronic charts?
 
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Doomedtheory

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While everyone develops their own unique style, I begin with what I see and then I go chronologically. I than do what I did which is basically the same as the chart that I filled out before. Some people say I provide too much detail, but it helped a lot to have the detail on more than one occasion.

What I see example.: walked up to apartment 110 at 1123 streetname pike, Fakecity, PA. Apartment 110 is a single level apartment, located on the third story of a six story building. The apartment has a white door with 110 printed in black. Inside, we found the patient sitting on the toilet in a tripod position, which is located to the immediate right of the apartment Door. Te patient appeared to be an adolescent female in a white dress. The patient also had widespread uticeria. In the sink was lipstick with a label that said it was strawberry flavored. A middle aged female was asleep present outside of the bathroom door. She had on scrubs and a name tag which read Ms. Firstname Lastname, RN, BSN


Above has no relation to an actual call AFAIK
 

Akulahawk

EMT-P/ED RN
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While everyone develops their own unique style, I begin with what I see and then I go chronologically. I than do what I did which is basically the same as the chart that I filled out before. Some people say I provide too much detail, but it helped a lot to have the detail on more than one occasion.

What I see example.: walked up to apartment 110 at 1123 streetname pike, Fakecity, PA. Apartment 110 is a single level apartment, located on the third story of a six story building. The apartment has a white door with 110 printed in black. Inside, we found the patient sitting on the toilet in a tripod position, which is located to the immediate right of the apartment Door. Te patient appeared to be an adolescent female in a white dress. The patient also had widespread uticeria. In the sink was lipstick with a label that said it was strawberry flavored. A middle aged female was asleep present outside of the bathroom door. She had on scrubs and a name tag which read Ms. Firstname Lastname, RN, BSN


Above has no relation to an actual call AFAIK
I would say that your narrative above is too wordy. The address/location info should be available elsewhere in the chart. You could start the above as: "Arrived on scene at a single level apartment on the third floor, accessible only via stairs. Patient, appearing to be a white adolescent female, was located in a bathroom, seated in an tripod position on the toilet. Pt noted to have widespread erythema with c/o urticaria. Pt states just used strawberry flavored lipstick, located in bathroom sink." The fact that the middle aged woman was sleeping near the door, was wearing scrubs with FN LN, RN, BSN on a badge may or may not be relevant that early on in the report. It could be noted later on once the relationship between the woman and the patient is known, and then that she was noted to be asleep on arrival (assuming she awoke while you were there).

This is shorter, avoids some double charting, and contains at least as much info as your more wordy version. I'm not saying to NOT chart stuff, just make it more compact.
 

photog

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IPatient was assessed and interviewed. Patient was assisted to cot and secured. Transported to St Farthest. Upon arrival report given to RN and signatures obtained.

Isn't it quite obvious that you assess and interview the patient? I thought that's what we are paid to do. As well as assist, secure, transport, report and get signatures. Maybe it isn't necessary to state the obvious?

walked up to apartment 110 at 1123 streetname pike, Fakecity, PA. Apartment 110 is a single level apartment, located on the third story of a six story building. The apartment has a white door with 110 printed in black. Inside, we found the patient sitting on the toilet in a tripod position, which is located to the immediate right of the apartment Door. Te patient appeared to be an adolescent female in a white dress. The patient also had widespread uticeria. In the sink was lipstick with a label that said it was strawberry flavored.

And this. It's a medical report, not a novel. There most likely is a field for the call address somewhere else. Also, if I was the doctor or nurse at the ER, I propably couldn't care less what colour the apartment door was or if it was a six story building. Nothing to do with the patient's condition or symptoms. To me, the actually useful information in your example were patient's position (sitting, lying on the floor etc), symptoms (urticaria) and the possible source for the symptoms (lipstick). Everything else is pretty much just waste of time, yours and mine. Though I would add a few other facts / finding not written in your example.

One could also write the report more or less in the structured "ISBAR" style, the same way we should do consultation calls, patient handovers and radio reports. ISBAR has in various studies been found to improve patient safety. In case someone hasn't heard about ISBAR, the acronym consists of:

I - Identify
S - Situation
B - Background
A - Assessment
R - Recommendation
 

Bullets

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Isn't it quite obvious that you assess and interview the patient? I thought that's what we are paid to do. As well as assist, secure, transport, report and get signatures. Maybe it isn't necessary to state the obvious?

Nothing is obvious.Not all calls get an assessment if they refuse, or we get cancelled. There is no where on my report to otherwise indicate that a patient was secured to the cot, transport destination is a hold over from when i learned on paper, sometimes i give report to an MD, a PA, or an NP. Or ALS gives report. Sometimes the patient cant sign i will state there why they couldnt



And this. It's a medical report, not a novel. There most likely is a field for the call address somewhere else. Also, if I was the doctor or nurse at the ER, I propably couldn't care less what colour the apartment door was or if it was a six story building. Nothing to do with the patient's condition or symptoms. To me, the actually useful information in your example were patient's position (sitting, lying on the floor etc), symptoms (urticaria) and the possible source for the symptoms (lipstick). Everything else is pretty much just waste of time, yours and mine. Though I would add a few other facts / finding not written in your example.

I was always told that scene description was important. If it was a 3rd floor walk up, that would indicate that our response getting up to the patient would be extended, same with moving him down. If the house was poorly marked, that would inhibit our response. Not just the hospital is reading this report
 

DesertMedic66

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Nothing is obvious.Not all calls get an assessment if they refuse, or we get cancelled. There is no where on my report to otherwise indicate that a patient was secured to the cot, transport destination is a hold over from when i learned on paper, sometimes i give report to an MD, a PA, or an NP. Or ALS gives report. Sometimes the patient cant sign i will state there why they couldnt





I was always told that scene description was important. If it was a 3rd floor walk up, that would indicate that our response getting up to the patient would be extended, same with moving him down. If the house was poorly marked, that would inhibit our response. Not just the hospital is reading this report
There is still useless information in that narrative which only waters it down and will make doctors and/or QI/QA only glance over it. The odds are the address is already elsewhere in the narrative. Sure, the patient being on the 3rd floor may play a party but we don’t need to know that the building is 6 stories tall. What if we responded to a hotel in Vegas with 60+ floors, would we really need to state “the patient is on the 10th floor of a 65 floor hotel”?

Once again the door color and the fact that there is a 110 painted in black letters on the door is completely irrelevant. Where the front door is located in relationship to the toilet is probably completely useless to anyone. The lipstick location is not very helpful and can be easily summed up “the patient states she is allergic to strawberries and accidently applied strawberry flavored lipstick 10 minutes ago”.

We are supposed to “paint a picture with words” in our narratives but only relevant findings should be included.

I have never heard a nursing or doctor narrative that says “I walked into a room with a glass door with the number 5 on it on the first floor of a 10 story hospital to locate this patient sitting on a hospital bed with white sheets. The location of the bed is at a 45 degree angle to the main door. There is a sink just opposite of the door that appears to have been cleaned recently with a paper towel dispenser located above it. Just to the left of the sink is the nurse’s computer on a white rolling stand about waist height. This patient is a well dressed 52 year old male complaining about chest pain for 5 hours that started while he was out shopping with his wife as she was looking at a fashionable yet affordable pair of high heels.” That painted a great picture of the scene however provided us with hardly any information and made it hard to skim through it to get the meat and potatoes of what is going on.
 

rujero

Emergency Services RN, NREMT
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Personally I used a fill in the blank style for IFTs and chronological narration for 911 response. The first transport of the day would be written from memory and copied and I would paste as needed. It looked something like this:

"A[#] dispatched priority [#] to [PLACE] to transport [AGE][GENDER] pt to [DESTINATION] for care related to [CONDITION]. Upon arrival, pt is [SUPINE] in a [BED], A/Ox[4] in no apparent distress, speaking in full sentences, SPO2 [96]% [on 2Lpm NC]. Pt denies CP, SOB, ABD pain, headache, dizziness, or any other complaint than for which she is being transported.

Pt --> Stretcher via [TRANSFER BOARD] and secured with 5 straps and 2 rails up. [Pt O2 therapy continued on portable tank at 2Lpm.] Stretcher --> locked into ambulance. [Pt O2 therapy continued with ambulance main O2 tank at 2Lpm.] Vitals during transport: HR [80, REGULAR], BP [146/96] with strong distal pulses. RR [18 REGULAR], SPO2 [96]% on [2]Lpm via [NC]. Pt remained stable during transport with vitals reassessed every 15 minutes as noted in record.

Upon arrival to [DESTINATION], [pt O2 switched to portable tank at 2Lpm.] Stretcher --> [PT ROOM] and [connected to facility wall O2 at 2Lpm]. pt transferred to [BED] via [TRANSFER BOARD] and secured with 2 side rails. Care transferred to RN with [BED in lowest position] and call light in hand. A[#] returned to service."


Here's an example of a chronological BLS 911 response call narrative:

"A19 dispatched priority 3 to Logan Airport for report of a man who was witnessed collapsing form standing height in Terminal A. Upon arrival, pt appears to be approx 50 y/o male in prone position non responsive. Pt log rolled with C-Spine precautions. Upon assessment pt is without carotid pulse with gasping respirations. ALS support activated and compressions are initiated. An OPA is inserted and BVM ventilation begins, equal chest rise is noted while ventilating. After two minutes the AED is applied. Compressions paused for analysis of rhythm. Shock advised and delivered, compressions resumed per the AED. BVM ventilation continued with visible chest rise and fall. ALS arrives and care is transferred to P6 crew. A19 remains on scene to support ALS."

So why were we dispatched? What did we find? What did we do? What was the outcome? In that order. Hope that helps!
-r
 
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vc85

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I don't really have a template but the way that I normally write mine mirrors the assessment order on the EMT exam (AVPU/A/B/C)

For example (fake pt)

Pt. Alert and Oriented to normal status. Airway clear and patent. Breathing rate elevated at 26 breaths per minute with marked expiratory wheezes bilaterally. SpO2 at 90 % room air increased to 94% on 4L O2 via nasal cannula. Nebulized albuterol treatment administered per protocol with significant improvements. Pt able to speak in short choppy sentences prior to treatment, full sentences after treatment. Skin intact with no active bleeding. Pulse rate tachycardic and thready. Pt transported to ER without incident and care transferred to RN.

Our PCRs have other boxes to chart exact vitals, movement devices and general impression/ pt statements so I don't put those in my main narrative
 

dksherman

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Image Trend has an option on the narrative page to push button and if all your info is filled out on the prior pages, it will produce a "completed" narrative. You just read through it and add or remove the information that is needed.
 
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