Receiving/Giving pt. Reports

Sasha said:
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.
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by looking at the wound, are you giving more of a chance that the wound will become infected? I was taught not to remove a bandage from a wound. I was trained to only treat and control bleeding not to redress a bandage. Plus if I did that It would have taking more than the 20 min I was onsence. (I was waiting for paperwork and a report. who would knew that the er was going to be busy at 02:30 on a sunday.) I would have to take the ace bandage off. take the 4" kling off and replace the abd. next I would also be moving the Pt's arm around since it was in a cast to keep the it imbolized. (orthoglass). I try transport my Pt's with min. amount of pn. It is better that way. And even it started to bleed through all that, I will still leave it there and add more bandage.
 
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Back on topic momentarily here's my method for giving a report. We get a bunch of information from dispatch, the patient, family, bystanders etc. I collect all that information and first thing I do is filter out the garbage. Once you're down to the bare essentials put the information in a logical order so the things that are most pertinent to the patients condition come out first while the nurse might still be listening. You want to be brief and to the point but most of the hospitals we go to like a more detailed report so we have to keep a perfect balance.

I think rid said it before but another good thing to remember is: patient demographics, what's wrong with patient, vital signs before treatment, what did you do, response to treatment and vital signs after treatment, ETA. To the best of my knowledge nobody has ever been fired for giving too much information and the nurse will ask questions if you don't give enough.

If you have a pocket guide mine has a guide to radio reports on the inside of the front cover that walks you through a pretty decent report just make sure you have all the information before you start trying to give a report.
 
Our ER actually provided us with a copy of what they want from incoming squads. They want:

Our squad
Patients age
Sex
CC
BP, Respirations, Pulse
Any important relevant info (CHF, LOC, etc)
Approx ETA

and that's about it.

Sidenote to emtfarva: We also do not remove a bandage to look at the wound. If it's dressed, it stays that way til a doctor or nurse removes it at the hospital. We can add more but we do not take it away.
 
Sidenote to emtfarva: We also do not remove a bandage to look at the wound. If it's dressed, it stays that way til a doctor or nurse removes it at the hospital. We can add more but we do not take it away.

That is the way I see it.
 
I take bandages off now. I went to a nursing home to pick up a PT that 'bumped their head' from an unwitnessed fall. I thought the dressing seemed a bit excessive so I wanted to see this bump. The facility didn't want us seeing he had a nice laceration above his eye. Had I not looked at that I wouldhave looked like a fool when giving a report at the ED. Then again it's depends on the call.
 
mikeN said:
I take bandages off now. I went to a nursing home to pick up a PT that 'bumped their head' from an unwitnessed fall. I thought the dressing seemed a bit excessive so I wanted to see this bump. The facility didn't want us seeing he had a nice laceration above his eye. Had I not looked at that I wouldhave looked like a fool when giving a report at the ED. Then again it's depends on the call.
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I always look at a wound at a nuring home if they are going to the ER for eval. This was a Hosp to Hosp transfer.
 
hospital to hospital. Screw that then, I'll leave the dressings on.
 
You can tell if a wound needs redressing because it will bleed through. If there is no blood leaking through the current dressing, why mess with it? The only time I've ever messed with an existing dressing was if it was falling off or in wilderness settings where repeated examination of the wounds is required.
 
When it comes to giving reports to the nurse who is in charge of the pt I basically say to her what I am going to or have written in my report. As we all know that report is a giant CYA so it is gonna give the nurse and the other caregivers everything they need to know.
With the charge nurse at the recieving area its just a really quick who it is and what is the CC. This is so they can determine where they are gonna put them.
When it comes to radio reports it's basically a short and sweet version of my written report.
"I am currently en-route to your facility with priority X XX year old male/female complaining of ________ their current vitals are ... We arrived to find the patient... We have established an IV with XXX currently pushed and (any other interventions). We are approx XX minutes from your facility see you upon arrival if there are any developments we will recontact."
 
Patient care report

Is this a radio report or is this the patient care report on the transfer of care at the bedside?
 
The bit in quotation marks is the radio report while en-route to an ER from a call. This is regular 911 calls not hospital to hospital stuff. Where I run it is required on all Priority 1 and 2 pts that you call the ER on your portable radio which is in my area a Motorola 800Mhz XT-4000. While it is not required for Priority 3 pts some people like myself do it anyways.
 
Lotsa good tips, espcially the old hands above.

Be the receiver's scout, not his Daily Planet reporter.
 
I think everyone has trouble learning how to give reports. I would write mine down so I would remember everything I wanted/needed to say.

Just practice. You will find what works for you.
 
I aim to have my radio/cell phone reports for NOTIFICATION be <30 seconds...


Them: XXXX Emergency: Command or notification? (or Physician or Nurse?)

Me: Notification

Them: OK… go ahead.

This is Jon with XXXX EMS, ALS / BLS notification. We are coming to you with a XX year old (fe)male from (Work, residence, XXX nursing home). Patient complains of ____________. Vitals are stable or ______ (if unstable). (If calling in for my paramedic, let them know that, and perhaps what he is working on for care. Give ETA, and any requests. We’ll have further report at bedside. Do you copy?




One recent one:

This is Jon with XXX EMS. ALS Notification. We are coming to you with an 88 year old female from XXXX Nursing Home. Patient is having severe respiratory distress, rales throughout, pulseox’ing in the 90’s on nonrebreather. Patient is on CPAP with minimal improvement. The paramedic is attempting to get IV access. We’ll see you in 5 minutes and we will need Respiratory standing by in the ED. Do you copy?

Alright, we’ll see you in 5 and we’ll page respiratory.



Now when I call for command – I’m going to give a reasonably full report… Chief complaint, Vitals, relevant physical exam, and WHY I’m calling the doc:
Are you ok with me bringing this to your facility? (for stuff that is borderline trauma criteria because patient fell down and is on Wafarin).
Patient wants to refuse further care and is CAOx4

Let them say their piece…. Answer their questions...

Command calls take time.
 
For radio reports I use the format that the county I work in has outlined for us. If my report is more than 20-30 seconds something is seriously wrong, or it's a STEMI patient and I'm justifying activating the Cath team.

If there is one thing I've learned about radio reports it is that the nurses WILL walk away from the radio if you take too long or start rambling off stable vitals; their whole list of meds; or all their allergies. Unless that information is 110% necessary for them to know ahead of time, don't say it on the radio.

Bedside reports I tend to do similar to what Rid outlined. I've noticed with doctors, especially the busy ones, if you present the information in an organized manner they are familiar with they tend to listen to you more.
 
You people are lucky that a facility will just take your word for vitals. Almost every ER in ABQ will ask you what the vitals ARE if you just tell them 'stable'
 
In Indianapolis where I was trained and worked for 10 years; at the bigger hospitals we gave the quick: age, sex, cc, and treatments, and GCS and just on critical patients. Most of the hospitals didn't care unless you were doing CPR or they were bleeding out..
In utah where I am now, they want a detailed report. had a nurse ask me on the phone for all of the patients vital signs, during the entire transport:L 2 patients 1hr 35min transport. the report took me 12 minutes, and I was 15 out when I called them: when I arrived at the ER they got mad cause I only gave them 2-3 min to get ready for them. The patients both had BLS knee injuries

go figure
 
Practice does make perfect. I have been working as a basic for 2 yrs. I usually give my reports just about the same. It all comes natural now. Here is an example.

Medic 6 to (Hospital)
Yes, We are currently enroute to your facility with a (age)(m/f) for the services of (ER doctor or specific doctor). Chief Complaint today is going to be (c/c). At this time the pt is (A&O x ___ with a GCS of ____). Have patient in the position of comfort with O2 via nasal cannula at a rate of____....( treatment..etc). BP is ____, HR_____ RR_____ and O2sat_____on Room Air or O2. We have an ETA of ________ any further questions.

Medic 6 out.
 
johnrsemt said:
In Indianapolis where I was trained and worked for 10 years; at the bigger hospitals we gave the quick: age, sex, cc, and treatments, and GCS and just on critical patients. Most of the hospitals didn't care unless you were doing CPR or they were bleeding out..
In utah where I am now, they want a detailed report. had a nurse ask me on the phone for all of the patients vital signs, during the entire transport:L 2 patients 1hr 35min transport. the report took me 12 minutes, and I was 15 out when I called them: when I arrived at the ER they got mad cause I only gave them 2-3 min to get ready for them. The patients both had BLS knee injuries go figure
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In most real world, after the first 30 seconds you would had been talking to dead air. Does their staff have nothing more to do?

You are going to give formal one upon arrival and a written one after that, redundantly redundant.
 
Our new radios piss me off. My reports have never been THAT long, but they have been set to automatically cut off after three seconds. Combine that with the fact that it's set to make you wait three seconds after you depress the switch before it keys in to prevent us from stepping on each other, you have about twelve seconds to lay out a report before the "BEEP BEEP" comes. You have to let go, rekey (another three seconds) and continue.

End result is that your reports come out sounding broken and disjointed. Even the most experienced medics are complaining about the things, and everyone is just buying their own personal radios to not have to deal with it.
 
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