Receiving/Giving pt. Reports

[Csybilly2003]

I just started working for a company that is mainly used for medical transfers. Yesterday in my training i was receiving and giving pt. reports and i was having problems with that. If anyone has any suggestions for me i would love to hear them. Thank you.

 

[mikie]

Practice makes perfect.

 

[rhan101277]

I gave my first report the other day to a doctor after a transfer from one hospital to the other. The doctors comes to me and ask me for vitals, is blood pressure stable, etc. I said his blood pressure was stable and he was alert and oriented, then i said he was a little bradycardia. Which afterwards made me wonder if he thought i was stupid. You either are or aren't. He was right on the edge of being so with the pulse in the low 60's, so I thought I would mention it. I know below 60 is considered bradycardia, but I was excited and in the moment oh well. Maybe I sounded educated.

 

[Sasha]

Practice practice practice.

While your driving along in the car, pick the driver of one of the cars around you, make up some medical or trauma problems for him, and then give your report to yourself in the car.

It's kinda fun if you can get creative with the problems. "Hyperroadragemia" was one of my favorites :]

 

[BossyCow]

One of the best teaching tools for giving reports is the questions that you are asked by the receiving party. Those are the items you left out. Do that a time or two and embarrassment becomes your teacher.

We have one ERT though that will always ask you for something weird. Bringing in a trauma pt and she'll ask if we did orthostatic pressures or what was their last meal.. not when.. what....

On the other extreme is a doc who only wants to hear age, gender and chief complaint. Nothing else, ever....

 

[medicdan]

I learned to give good Triage reports fairly quickly because at the ER we feed to most often, the nurse will start taking to the patient if they dont like your report. It is also worth noting how the facility uses the information-- different hospitals note it differently in their software, so you need to give it in a specific order.

I learned, at first, to write it down linearly on a notecard, with all the information in one place. It sounds something like this.

Good Morning. Here we have Mr. John Smith, age XX, MRN/SSN 123-45-6789, coming from home complaining of abd pain. He ate a large lunch a few hours ago. The discomfort started 40 min later. Denies CP/SOB. His vitals are stable (they dont need to know details, as my partner is getting a set on the hospital's machine at the same time). Hx of XXXX. He has an allergy to PCN, and is on X, X, X and X meds. We put him on X liters of O2. etc.
Thats all they need to know. The nurse now knows what priority the patient is, and has the important info in the computer.

By the end, you should have gotten through SAMPLE and OPQRST.

remember, you are your patient's advocate, and the immediate treatment they get is dependent on the quality, completeness, and conciseness of your report.

 

[Veneficus]

On the other extreme is a doc who only wants to hear age, gender and chief complaint. Nothing else, ever....

Just so you know some docs only want this information so they do not form biased judgments prior to seeing the pt themselves. (which is a good practice) they usually do look at the information you provide after so it is important to write as much as possible even if you are not asked for it, because once you leave, there is no practical way to get it.

 

[MMiz]

Like others said, it just takes practice. Some doctors/nurses want more complete reports than others.

I usually do a: "This is John Smith, a 65 y/o male complaining of... xxx." A modified version of SAMPLE history, throw out the vitals, and then discuss our treatments.

 

[rhan101277]

Well this was a transfer so i wasn't really prepared for a report. He asked me questions and I gave answers. I did learn to be more prepared, they put him in a wheelchair and that was that.

 

[Veneficus]

something i personally like in reports is things I can't readily see. If you bring in a patient who is telling somebody at a desk their SSN telling me they are A&O is sort of redundant.

 

[BossyCow]

Just so you know some docs only want this information so they do not form biased judgments prior to seeing the pt themselves. (which is a good practice) they usually do look at the information you provide after so it is important to write as much as possible even if you are not asked for it, because once you leave, there is no practical way to get it.

Just so you know, I already knew that. Was just providing examples of the opposite ends of the spectrum. Too often new EMTs are told that "This is the way it's done" and "You must do it this way only to find that different facilities, different docs, different systems do things very differently.

The doc I mentioned is my husband's fishing/hunting buddy.

 

[TransportJockey]

Practice practice practice.

when I worked for an IFT company, my first six months there I was an attend only. That mean 8-9 reports every shift, 4 days a week, at least. Giving report became second nature after a few weeks.

The more nerve wracking calls were ones from 'SNFs' that should have been 911 calls, but they didn't want to hurt their stats. That meant a radio report to the facility and a report to the RN taking the pt and maybe MD/PA

 

[Ridryder911]

Usually radio reports are to be given in a short precise manner, the main emphasis to forewarn the ED of what is coming in to prepare them. What room can be available, resources needed, and to mainly prepare for the patient. All of this can be done in <1 minute.

Upon arrival; I personally give a hx similar to what physicians give to each other.

Age/Consciousness, Sex

IPHX- what occurred, C/C, etc. i.e MVA, Chest pain for 2 hours.

PMHX Brief specific-cardiac, COPD, CA, etc.

Physical Findings- usually specific or negative. i.e. bruising chest wall, but good lung sounds in all fields, as well as heart tones clear.

Tx EMS and PTA ECG to med.'s

Results or changes

All of this can occurr within a few minutes.

I have found to use specific terms but be sure it is accurate and pronounced accurately. Simple terms if one does know them. It is much beter to use such than to be thought as foolish and not as to depend upon .

As many others describe practice makes perfect.

R/r 911

 

[emtfarva]

It takes time. I give reports to nursing home all the time. Sometimes they listen sometimes they don't. I still give a report. Early this morning I took my first GSW to Boston and I got to give report twice. I gave it to traige and then to the Pt's nurse and doctors. It was kinda fun. They even let me take a look at it. I have been doing this for Two years and I still get flustered on 911 calls. What I have learned is if the hosp wants some info from you they will ask you. Otherwise I just give a short report. It goes like this:

This Mr. So and So, who is 39 y/o m c/o (whatever). (PMHx) and meds. Last known VS. And anything I think is important that the Hosp should know. If it is a Hosp to Hosp transfer I will also tell them any interventions that the sending Hosp might have done.

I have also learned that when doing a Radio patch they like it short and sweet. I usally tell them the Age, sex, cc, I tell them that VS are wnl if they are or tell them VS if they abnormal. Then eta and ask if they have any questions. I will tell them if I did any interventions also.

 

[Sasha]

They even let me take a look at it

You should have looked at it when you picked the patient up.

 

[emtfarva]

You should have looked at it when you picked the patient up.

not when it was splinted and wrapped for the transport. I came from another hosp. ^_^

 

[Sasha]

not when it was splinted and wrapped for the transport. I came from another hosp. ^_^

When I did IFT we were still expected to look at the wound to document in our report, then redress.

 

[TransportJockey]

When I did IFT we were still expected to look at the wound to document in our report, then redress.

The one exception we had was if it was plastered. Then we were just to leave it

 

[emtfarva]

When I did IFT we were still expected to look at the wound to document in our report, then redress.

the sending hosp would kill me if I did that. Anyway if it is bleeding I would never take the previous bandage off just in case it was trying to clot. I get a report from the nurse. They tell me what it looks like. Plus I don't have Xray vision and I wouldn't have been able to tell that the ulna was broken with fragments by taking off the bandage and rewraping it. When I do write it in my report I add the words per nsg staff.

 

[Sasha]

the sending hosp would kill me if I did that. Anyway if it is bleeding I would never take the previous bandage off just in case it was trying to clot. I get a report from the nurse. They tell me what it looks like. Plus I don't have Xray vision and I wouldn't have been able to tell that the ulna was broken with fragments by taking off the bandage and rewraping it. When I do write it in my report I add the words per nsg staff.

You don't need to know what the ulna looked like or if it was broken to look at the wound, here you were expected to document the size and shape of the wound, then redress.