So I'm almost done with Paramedic school, and my reports have increased in quality exponentially, but I'm still having trouble wording some things. For example "Airway, breathing and circulation are stable and intact" or "vitals are within normal limits". I would call those okay, but the stable/intact/WNL seem too open to interpretation. Any suggestions on how to make my reports clearer?
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- Thread starter Pkreilley
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Achilles
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WNL= We Never Looked.
Here's what I like to do.
Unit dispatched to unknown medical.
ATF 50 YO M lying prone in bathroom.
PT AOx4
PTS wife stated blah blah blah.
PT denies chest pain and states he is not in any respiratory distress.
PT transferred to stretcher w/o incident.
Stretcher secured inside ambulance.
Vitals taken inside ambulance (we have a section on our computers that we put vitals in)
Radio report given.
PT transported priority 3 to xxx.
PT transferred from stretcher to bed w/o incident.
Oral report given to nurse.
Physician signed.
Pt care transferred.
Unit cleared.
Basically you're telling a story of everything that happened.
Our program also bass section for signatures, names, times, procedures and all the other fun stuff.
Here's what I like to do.
Unit dispatched to unknown medical.
ATF 50 YO M lying prone in bathroom.
PT AOx4
PTS wife stated blah blah blah.
PT denies chest pain and states he is not in any respiratory distress.
PT transferred to stretcher w/o incident.
Stretcher secured inside ambulance.
Vitals taken inside ambulance (we have a section on our computers that we put vitals in)
Radio report given.
PT transported priority 3 to xxx.
PT transferred from stretcher to bed w/o incident.
Oral report given to nurse.
Physician signed.
Pt care transferred.
Unit cleared.
Basically you're telling a story of everything that happened.
Our program also bass section for signatures, names, times, procedures and all the other fun stuff.
JPINFV
Gadfly
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First, are we talking about written report vs radio report vs hand off report?
Talking about the written report, it depends on what's on the overall report. "Vitals WNL" isn't a problem, in my opinion, provided the actual numbers are someplace else in the report and... well... within normal limits. If they are just out, than something along the lines of "pulse is slightly elevated, but not concerning at this time" would work (after all, there's elevated and ELEVATED). Next, I would cover each section individually instead of groups. "Airway patent, lung sounds clear, no rales, wheezes, rhonchi, heart is at a regular rate, no murmurs, rubs, gallops. Abdomen is soft, non-tender, positive bowel sounds times 4."
For example, I'm currently rotating through pain medicine right now. When I dictate my physical exam on a clinic patient, the objective section looks something like this for a patient with a normal exam focusing on the lumbar region (e.g. a patient with spinal foramen stenosis).
O: Vitals ______
General: Well developed, well nourished male, no acute distress.
CV: Regular rate, no murmurs, rubs. gallops.
Resp: Clear to auscultation bilaterally, no wheezes, rales, rhonchi.
Abdomen: Soft, non-tender, positive bowel sounds times 4
Neuro: A/Ox4, muscle strength 5/5 and equal bilaterally in lower extremities, DTR 2/4 and equal bilaterally at S1-S2 [Achilles ligament] and L3-L4 [patellar ligament], sensory is intact to light touch and equal bilaterally in lower extremities, gait is balanced, no pain elicited on extension and flexion of the lumbar, straight leg raise negative bilaterally.
If you have the chance to look at Bates Guide to the Physical Exam, it includes the negative documentation for both a general physical exam and a focused physical exam when they cover each exam.
Talking about the written report, it depends on what's on the overall report. "Vitals WNL" isn't a problem, in my opinion, provided the actual numbers are someplace else in the report and... well... within normal limits. If they are just out, than something along the lines of "pulse is slightly elevated, but not concerning at this time" would work (after all, there's elevated and ELEVATED). Next, I would cover each section individually instead of groups. "Airway patent, lung sounds clear, no rales, wheezes, rhonchi, heart is at a regular rate, no murmurs, rubs, gallops. Abdomen is soft, non-tender, positive bowel sounds times 4."
For example, I'm currently rotating through pain medicine right now. When I dictate my physical exam on a clinic patient, the objective section looks something like this for a patient with a normal exam focusing on the lumbar region (e.g. a patient with spinal foramen stenosis).
O: Vitals ______
General: Well developed, well nourished male, no acute distress.
CV: Regular rate, no murmurs, rubs. gallops.
Resp: Clear to auscultation bilaterally, no wheezes, rales, rhonchi.
Abdomen: Soft, non-tender, positive bowel sounds times 4
Neuro: A/Ox4, muscle strength 5/5 and equal bilaterally in lower extremities, DTR 2/4 and equal bilaterally at S1-S2 [Achilles ligament] and L3-L4 [patellar ligament], sensory is intact to light touch and equal bilaterally in lower extremities, gait is balanced, no pain elicited on extension and flexion of the lumbar, straight leg raise negative bilaterally.
If you have the chance to look at Bates Guide to the Physical Exam, it includes the negative documentation for both a general physical exam and a focused physical exam when they cover each exam.
EMTnurse
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So, one of the things I've learned in nursing school is that what we do in practice is different than what we do in school. In the field, we use WDL all the time. Hell, even in the hospital computer charting, WDL is what you use if there is nothing wrong. However, in school they want to see that you know what those defined limits are. So, for example, if I were assessing circulation, instead of putting "capillary refill time was normal", I'd say "capillary refill time was <3 seconds" etc.
JPINFV
Gadfly
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The problem with WNL for an entire section is what's WNL? What did you check? What did you listen for? "WNL" for a neurological exam is utterly useless.
EMTnurse
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I don't disagree, but specifically in the hospital setting, you chart by exception. Whereas my EMS report would have a step by step if everything I checked, and my exact findings, in the hospital your choice is to make an abnormal finding, or WDL.
JPINFV
Gadfly
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Difference between nursing documentation and physician documentation, and one of the reason why when I'm writing a progress note (either on a consult service like I am right now or when I'm rotating with the primary team) I don't read the specific shift assessments on the EMR. I do, however, check the nursing notes and, when on a consult service, the primary medical team's progress note.
EMTnurse
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Definitely, since we more or less just check boxes with the random comment here or there. We don't get the story-telling aspect of a report.
My point to the poster was that in the school setting, specifically, the instructors want to know that you know what normal is. Anyone can do an assessment and write normal, but try want to see that you can recall normal when needed.
My point to the poster was that in the school setting, specifically, the instructors want to know that you know what normal is. Anyone can do an assessment and write normal, but try want to see that you can recall normal when needed.
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My own documentation, as I'm in nursing school right now, is simply to follow the facility guidelines... if their EMR system wants CBE, then I'll do that. If they want what I found, I'll do that. I will NOT chart by exception when what's considered "normal" isn't defined. When that happens, I simply chart what I actually found. Big deal..
What I've seen a lot of in the nursing notes is, quite literally, something along the lines of "Patient assessment and vitals charted in EMR. Report received from Day Shift. Plan of care reviewed, appropriate, and discussed with patient. Signed Rodney Dangerfield, RN." Many of the RN's simply use a template and not expand beyond the 2 or 3 lines of that template. (As you all know, Rodney gets no respect, no respect at all...)
My habit is to take that quick template and actually write a note that is essentially a snapshot of my findings. No, it's not as detailed as a Progress Note or H&P, but it's to give the reader an impression about the patient and whether or not the reader should look deeper into the chart.
I'm glad that there are people like you that actually read the nurse's notes. Given that I can type relatively quickly, it just reinforces that I should continue to write my notes the way that I do so that you get the gist of what's going on.
JPINFV
Gadfly
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The individual notes are really important because it gives a clue about what's happening the 90% of the time I'm not there. With EMR, it's great because I don't even have to be on the floor to see what's going on (when I was on primary teams, I'd find an open computer and do all of my skeletons (VS, meds, labs, etc) at one time, and then pop up to see the patients and drop the note when appropriate.
Just, for the love of all that is good and holy, DON'T TYPE IN ALL CAPS. also dont type in all lower case with no punctuation
Just, for the love of all that is good and holy, DON'T TYPE IN ALL CAPS. also dont type in all lower case with no punctuation
mycrofft
Still crazy but elsewhere
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As a nurse and former EMT...
Lawyers love "WNL". Also assertions of "Stable" without recorded serial evaluation notes.
On the stand, or in your supervisor's office, expect to hear "What constitutes normal (or intact or stable) in this sort of case?". Then you have to back it up. After twenty years of seeing patients at sick call and man-downs I was still occasionally called on this and more than once had to assume an icy stare and look righteous while inside I was saying "Oh, shazbat!".
Be that as it may, follow your employer's guidelines and exceed them. Talk to the people who have to read your notes so you get some feedback.
As a technician, and hence theoretically limited to following protocols and not making diagnoses (yes I know), recording diagnoses and not data can trip you up. It may work 98% of the time, but when that 2% intersects with a lawsuit or a death then you are on the hotplate.
Lawyers love "WNL". Also assertions of "Stable" without recorded serial evaluation notes.
On the stand, or in your supervisor's office, expect to hear "What constitutes normal (or intact or stable) in this sort of case?". Then you have to back it up. After twenty years of seeing patients at sick call and man-downs I was still occasionally called on this and more than once had to assume an icy stare and look righteous while inside I was saying "Oh, shazbat!".
Be that as it may, follow your employer's guidelines and exceed them. Talk to the people who have to read your notes so you get some feedback.
As a technician, and hence theoretically limited to following protocols and not making diagnoses (yes I know), recording diagnoses and not data can trip you up. It may work 98% of the time, but when that 2% intersects with a lawsuit or a death then you are on the hotplate.
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The only time I'll ever type in all caps is if work requires it, or the caps lock key on all the computers is broken.
I also prefer to use punctuations. After all, proper punctuation does save lives... Shall we eat Grandma?:rofl:Pended notes are great! If/when we're required to have our clinical instructors review our notes, keeping them pended does save some aggravation for that first one or two that he/she reviews with us in person. After that, I might write it, pend it, look something up, ponder it a minute or three, re-read it to ensure clarity (and find any missing words), and then sign it.
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WNL is a commonly accepted abbreviation that is not ambiguous. It simply means that your finding was not contributory.
You hear a lot of urban legends about people being deposed and "hung out to dry" over documentation, but in reality it is an extreme rarity that someone's care meets the standard but they end up in serious trouble just because they used an abbreviation that some people don't like or they forgot to document the color of the patient's underwear or the humidity level the day of the call.
It is a myth that the more you write, the better protected you are. The more you write, the more opportunity there is for a predatory lawyer to find an opportunity to exploit. Charting by exception is a more practical and quite possibly a more legally defensible documentation strategy.
The point of documentation is not to give as much info as possible, or even necessarily to "paint a picture". It is to convey clearly and succinctly what you found, what you did, and that your care met the standard. In some cases, doing that well does require a lot of explanation and detail. But usually not.
mycrofft
Still crazy but elsewhere
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As I wrote, it works 98% of the time.
Attorney: Nurse Mycrofft, please define "normal limits".
Nurse Mycrofft: Are you implying I don't know what normal is?
Attorney: Just answer the question please. Can you cite the references guiding your evaluation of "normal".
We worked under a grand jury decree and had a very litigious population of patients. I used WNL a lot but always had vital or observational notes. WNL was in the commentary or verbal report but the vitals and observations were dated and timed in there, too. Imagine how small ICU nursing or tech records would be if they could write WNL and go off shift?
Oh, and the other attorney question: "If the patient was "normal", what were you doing treating them?".
Attorney: Nurse Mycrofft, please define "normal limits".
Nurse Mycrofft: Are you implying I don't know what normal is?
Attorney: Just answer the question please. Can you cite the references guiding your evaluation of "normal".
We worked under a grand jury decree and had a very litigious population of patients. I used WNL a lot but always had vital or observational notes. WNL was in the commentary or verbal report but the vitals and observations were dated and timed in there, too. Imagine how small ICU nursing or tech records would be if they could write WNL and go off shift?
Oh, and the other attorney question: "If the patient was "normal", what were you doing treating them?".