Question regarding ePCR

[paradoxicalmotion]

For the past couple years I've worked as a paramedic (and as an EMT for a couple years before that) for a service that uses paper reports with a very large space for a narrative, and very little of the "short answer" variety of boxes (e.g. "Allergies: ____" or "Medications:______"). Working there I became very comfortable with writing out a narrative that covered EVERYTHING. Now I've made the move to a service that uses ImageTrend ePCR so I've had to do a little adjusting. There are medics at this service that will literally take an hour to write a report and they end up writing a narrative very similar to what I used previously, but a significant amount of this information gets duplicated in "short answer" boxes. On the other hand, there are medics that take less time to write a report, and they essentially use the narrative only to 'tell the story' and cover what doesn't come across in the 'short answer' fields. I've also noticed these medics don't include a physical exam in their narratives, and instead tend to be very detailed in their use of the body diagram.

I just wanted to get some feedback from people on their experience with this. It makes sense to me that what you put elsewhere in the report doesn't necessarily need to be duplicated in the narrative, but having spent several years putting everything in my narrative, I think I just need some convincing. Any help is appreciated.

 

[unleashedfury]

I was taught to do your story in the narrative, however vitals PMH, Meds and allergies can be noted as "see flow chart"

I've always written my narratives as Dispatch, Arrived to find, Chief Complaint, HPI/MOI, Assessment, Treatment and Transport.

I've recently been switched over to EMS charts. which doesn't include a narrative section. which makes a bit confusing for me.

 

[NomadicMedic]

We use image trend and I tend to write a very descriptive narrative, although I may duplicate some info from procedures and med admin, I generally don't include the PT's home meds, allergies, PMHX or anything else that is covered in the check boxes unless its germane to the present complaint, for example, a chest pain patient with a history of past MI and stent placement. I'd ask the professional standards person at your agency what they would like to see in the chart. I'm surprised that you don't have a charting standard to work from.

 

[Mariemt]

I do not include in the narrative anything already covered unless it caused a complication etc.