Run Sheets

[jtb_E10]

What kind of format do you use when writing your run reports?

 

[Ridryder911]

I have just finished a presentation on charting and documentation. As this is one of the poorest areas most of the medics obtain information on. I prefer the CHART method, due to it's precise and more narrative and pertains to more of what EMS does. SOAP is a great method as well, but the Plan portion is more for an on-going treatment modality. Now, I prefer the SOAP method for in-hospital usage, again re-evaluating what has occurred and making new plans.

 

[Shishkabob]

I use SOAP, as that is what I was originally taught. Works for me.

 

[DrankTheKoolaid]

re

modified soap

scene info
c/c
px
tx
and finish with any changes with patient en route

 

[Shishkabob]

modified soap

scene info
c/c
px
tx
and finish with any changes with patient en route

siccpxtx?!

 

[medicdan]

I've been converted to a rubric of sorts by one of the services I work with.

SC (Scene): OAF XXy/o X, CA&Ox?, position ICO XX. CC. HPI. PE. TX. TP.

 

[TransportJockey]

Most of the local services (and I like it better too) use D-CHART-E. The rest use either SOAP or one uses SBAR (which is what the major hospitals here use)

 

[Epi-do]

I typically write my reports chronologically. I was taught SOAP & CHART as well, but have never worked any place that had a specified preference.

As long as all of the info is there, that is what is important. The more reports you write, the easier it will be to do. Also, you will find a system that works best for you. Then make it a habit to do your narratives using the same basic format every time.

 

[ResTech]

I use a format that is pretty generalized I guess... kinda made it my own and use the exact same format on every PCR. I hate the SOAP, CHART, and other condensed methods.

Here is my format:

[Intro the reader to the call for dispatch, what I found immediately upon arrival, and who was present with the pt. when I got there]

D/P to the indicated incident location for a xx y/o male pt. for chest pain. AOS to encounter patient sitting on a chair in the kitchen. Pt's. wife present upon arrival.

C/C: "whatever chief complaint it"

HPI: "History of Present Illness". Detailed but brief history of the current illness or injury and events that led up to it. I also include vehicle damage in this section if an MVC.

PE" "Physical Exam"

TX & DISPOSITION: All treatments rendered, by whom, indications for such, evaluation post-tx, how we transferred the pt, transport mode, seating position / position of comfort, (semi-fowler's, etc), safety belts secured, supportive care provided, notification to hospital, any orders or special instructions received, any problems encountered during transport, arrival at destination and transfer of care at bedside, also note transfer of any medical records received from a residence or extended care facility/dr officer. And departed hospita available.

[Meds, Allergies, and PMH, are in other sections of the PCR so no need to be redundant in the narrative]

We use web based reporting in Maryland called EMAIS... and also have used a software program called EMstat... a very awesome program.

 

[jtb_E10]

That is prtty much what i use ResTech...I learned that from the training coordinater from the service i used to work for right after i got my cert....I was just curious as to how everyone else did theirs. Kinda interesting to me for some reason...

 

[ResTech]

Documentation is an art...

 

[Ridryder911]

I use a format that is pretty generalized I guess... kinda made it my own and use the exact same format on every PCR. I hate the SOAP, CHART, and other condensed methods.

Here is my format:

[Intro the reader to the call for dispatch, what I found immediately upon arrival, and who was present with the pt. when I got there]

D/P to the indicated incident location for a xx y/o male pt. for chest pain. AOS to encounter patient sitting on a chair in the kitchen. Pt's. wife present upon arrival.

C/C: "whatever chief complaint it"

HPI: "History of Present Illness". Detailed but brief history of the current illness or injury and events that led up to it. I also include vehicle damage in this section if an MVC.

PE" "Physical Exam"

TX & DISPOSITION: All treatments rendered, by whom, indications for such, evaluation post-tx, how we transferred the pt, transport mode, seating position / position of comfort, (semi-fowler's, etc), safety belts secured, supportive care provided, notification to hospital, any orders or special instructions received, any problems encountered during transport, arrival at destination and transfer of care at bedside, also note transfer of any medical records received from a residence or extended care facility/dr officer. And departed hospita available.

[Meds, Allergies, and PMH, are in other sections of the PCR so no need to be redundant in the narrative]

We use web based reporting in Maryland called EMAIS... and also have used a software program called EMstat... a very awesome program.

That is actually the CHART method. Condensing has nothing to do with it, rather to define it into sections. Most condensed because of e-pcr and NEMSIS has their mandated 40+ required fields, that all states will be adopting within the next couple of years. So patient narrative is usually smaller because again, portions are already previously documented in another field.

R/r 911

 

[EMT11KDL]

I use D SOAP, Dispatch Information than write the SOAP format. It works for great for me,

 

[marineman]

We are required to use RCHART. I always used to prefer a chronological story type report but once I got used to this format it is much quicker and precise leaving out much of the fluff that I used to include.

 

[ffemt8978]

I prefer CHART, but the state mandates that we SOAP here.

 

[Hockey]

I write it in Hockey's format


I write it exactly what happened from how I responded then when I arrived, what did I find. What is the patients chief complaint. All the boring stuff. Transported. Turned over care

None of that SOAP CHART stuff for me. I write exactly from the minute I am assigned to the call till the end of the call.

 

[exodus]

Chart :] :] :] :]

 

[Shishkabob]

I write exactly from the minute I am assigned to the call till the end of the call.

"Radio crackles. We get dispatched. I spill my donut on my shirt and think 'darn'. We drive. Sirens blare. We arrive. I open my door and get out, and then close it. I grab the jump bag. I take 5 steps to the door and think 'Why are we so close to the door?' I see the pt"


That'd get old after a while

 

[LucidResq]

"Radio crackles. We get dispatched. I spill my donut on my shirt and think 'darn'. We drive. Sirens blare. We arrive. I open my door and get out, and then close it. I grab the jump bag. I take 5 steps to the door and think 'Why are we so close to the door?' I see the pt"


That'd get old after a while

Oh I like it! It's like an EMS film noir script.

 

[Sasha]

What kind of format do you use when writing your run reports?

Whichever format my employer wants.