Run Sheets

[wyoskibum]

I use a variation of the CHART method called LCHARTI:

(Location):

(C/C):

(HxPI):

(Assessment):

(Rx):

(Transport):

(Impression):

 

[ResTech]

Whichever format my employer wants.

Employer's should not be telling their personnel what kind of format to use. As long as all elements of the call are documented and documented well it doesn't matter which format.

For me, I take my documentation personal and given the legal nature and the defensibility my PCR will serve in a court room, I will choose to document in a format that I am comfortable with and has been proven to be effective over the years.

 

[Ridryder911]

Employer's should not be telling their personnel what kind of format to use. As long as all elements of the call are documented and documented well it doesn't matter which format.

For me, I take my documentation personal and given the legal nature and the defensibility my PCR will serve in a court room, I will choose to document in a format that I am comfortable with and has been proven to be effective over the years.

Sorry, you don't own the chart; your employer does. Have you worked in EMS yet? Ever head of e-pcr or ever done any real charting? So, your going to tell your employer that your not going to follow their charting method... yeah, sure.

Most e-pcr has a method built in I do doubt that any employee is going to dictate what method they prefer over their half million dollar system. Guess which will be changed?

R/r 911

 

[paramedicmike]

Employer's should not be telling their personnel what kind of format to use. As long as all elements of the call are documented and documented well it doesn't matter which format.

For me, I take my documentation personal and given the legal nature and the defensibility my PCR will serve in a court room, I will choose to document in a format that I am comfortable with and has been proven to be effective over the years.

Aren't you using EMAIS? In your case, it's not really the employer dictating to you how you chart it's the State. Employer or State mandate, they do have it within their rights to tell you how to chart. From a legal perspective it suits their interests to do so as they'll certainly be named in the lawsuit when you screw up (a general you, not you specifically).

C'mon. I thought Austin would've done a better job teaching you this.

 

[ResTech]

Have you worked in EMS yet? Ever head of e-pcr or ever done any real charting? So, your going to tell your employer that your not going to follow their charting method... yeah, sure.

I've done about 15 years of patient care documentation (nurses do charting) as a career provider, active volunteer, and Deputy Chief of EMS operations during that time period. I have a real knack for complete and accurate documentation and is a part of my job that I place a high level of importance. I'm not just talking out of my *** here. And since your calling me out, I get QA praise all the time from the QA ppl and my preceptors. I almost hate turning in my reports because I don't like the attention and "atta boy's" all the time. So this is an area I am quite fluent and experienced with.

And since u asked.... I'm experienced with many different programs used for electronic data collection and PCR submission (EMstat from Med-Media, Code 3, EMMA, EMAIS)... and I've done my fair share of fill in the dots and hand written narratives as well back in the day.

Most "e-pcr methods" of automating narratives sucks and I have never seen any that I would recommend.

Aren't you using EMAIS? In your case, it's not really the employer dictating to you how you chart it's the State.

Incorrect... Maryland does not dictate how I or any other provider writes their narrative. All they care about is that all of the check boxes are checked for their statistical purposes. When it comes to the narrative its provider preference as long as all identified parameters and care elements are covered.

Employer or State mandate, they do have it within their rights to tell you how to chart.

Your right, they do. However, any employer is going to recognize that documentation style is individualized and as long as all aspects of the call are documented it doesn't matter what style is used. If I were an employer, I would want my personnel using a style that they are comfortable with to make the documentation easier on them and in a format they are going to be comfortable with if ever called to defend it.

 

[ResTech]

Sorry, you don't own the chart; your employer does.

While I may not physically own the report (which I never insinuated that I did), every word, thought, and action I documented are my own and I am personally accountable for them. They are a direct reflection of myself as an EMS practitioner and my EMS service. So in a sense, I am part owner of the report when it has my signature on it and its my future that may depend on it.

 

[paramedicmike]

First you said this:

When it comes to the narrative its provider preference as long as all identified parameters and care elements are covered.

Then you said this:

Your right, they do. [Regarding mandating charting styles]

So which is it? First you're saying that no one can dictate to you how you chart then you say they can.

However, any employer is going to recognize that documentation style is individualized and as long as all aspects of the call are documented it doesn't matter what style is used.

Time to step out of the exceedingly tiny world that is Washington County. Any employer within the County may hold this view. But not any employer out there. In fact, very few employers outside WashCo have such lax views when it comes to documentation and allowing such freedom of their employees.

I fully understand how insular and tiny Washington County EMS is. In fact, I know first hand how insular and tiny it is. That's one of the big reasons why I don't work there anymore.

If I were an employer, I would want my personnel using a style that they are comfortable with to make the documentation easier on them and in a format they are going to be comfortable with if ever called to defend it.

Well, when you're the employer you can do that. But will you and the medical director then be willing to accept the liability when your organization is named in the suit based on the charting of one of your employees? If you are, then more power to you. And I hope you have a good lawyer.

 

[ResTech]

First you said this:

Quote:
Originally Posted by ResTech
When it comes to the narrative its provider preference as long as all identified parameters and care elements are covered.
Then you said this:

Quote:
Your right, they do. [Regarding mandating charting styles]
So which is it? First you're saying that no one can dictate to you how you chart then you say they can.

The first quote I made is a general statement and rule based on good practice. A provider who has full responsibility for their patient's care, also has full responsibility for their patient care documentation. And patient care documentation is every bit as important as the direct patient care provided. And technically yes, an employer can be dictative and say "this is how every report from every single provider is going to be written"... but that is really a disservice to the entire organization to operate like that. Micromanagement is very poorly conceived in general and is especially looked down upon in EMS.

Time to step out of the exceedingly tiny world that is Washington County. Any employer within the County may hold this view. But not any employer out there. In fact, very few employers outside WashCo have such lax views when it comes to documentation and allowing such freedom of their employees.

I fully understand how insular and tiny Washington County EMS is. In fact, I know first hand how insular and tiny it is. That's one of the big reasons why I don't work there anymore.

First, I am not in the "exceedingly tiny world that is Washington County". I served in three different counties (two for a very long time in PA) and have a diverse experience base in what is expected for documentation. I'm not stating an opinion and advocating based on one station's or counties practice but instead advocating good, sound rules of practice that should be applicable everywhere. Every station I have been affiliated with has been relaxed on which style of narrative format providers use.

** BTW, I only do clinicals in Washington County and reside there. My experiences as a provider happened way before Washington County. But nice to see someone local on here **

Regardless if a station mandates a particular narrative style or not, where is the guarantee that quality documentation is going to be produced? Documentation is a skill just like the many others that we learn. Some do an excellent job and some not. If a provider cannot write, has poor spelling and grammar, or cannot articulate their thoughts and call events in the narrative section, then no mandated narrative style is going to makeup for that. This is why narrative style isn't all that important as long as ALL critical elements of the call are documented for both legality and billing purposes. CONTENT OF THE REPORT IS WHAT IS IMPORTANT... NOT NARRATIVE FORMAT STYLE.

 

[WuLabsWuTecH]

No body ever read them for the last year i worked as an EMT except for the billing people so I just started writing and it was in a paragraph (or 3) and temporal. The assessments and treatments were listed separately.

I think i'm going to use SOAP or CHART method now that I work in situations that my charts are actually going to be read!

My previous employer didn't care as long as the information was all down somewhere on it in case someone ever did want to refer back to it. Currently these guys prefer CHART, but are OK with SOAP, SBAR, anoy of those modified, or anything else as long as its clear and concise.

 

[NomadicMedic]

SOAP is required where I work.

... and no, I don't work at a car wash or Laundromat.

 

[Sasha]

Employer's should not be telling their personnel what kind of format to use. As long as all elements of the call are documented and documented well it doesn't matter which format.

For me, I take my documentation personal and given the legal nature and the defensibility my PCR will serve in a court room, I will choose to document in a format that I am comfortable with and has been proven to be effective over the years.

You see, my first job I tried to do what I wanted despite what my employer said and realized how stupid that was. An employer has every right to dictate how they want the documentation, they are vulnerable in lawsuits too. It's not a big deal to switch from SOAP, to CHART, to pure narrative, etc. I know them all well enough to write good reports using whatever method they ask for or am willing to learn the format my employer wants their reports written in. They are all basically the same.

 

[djmedic913]

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

I take a bit of everything...

I always start with the dispatch info, how I found the Pt upon arriving (sitting, standing, supine, etc) and there CAO level (with an explanation if it is not CAO x3 or 4)

Then my HPI [history of present illness]: this everything that is said from bystanders, FD, PD, family, Pt that prior to me getting on scene and sometimes other things while I am there.

then my assessment section. I break this down to body systems to find it easier to find if a MD asks about anything in particular.
Explain anything out of normal limits.
so my breakdown:
[HEENT] Head,ears, eyes, nose and throat. Are they PEARL? if not what is different. level and loss of consciousness? GCS? if not 15 or 3 break down of GCS. JVD? tracheal deviation? speech?, explain speech, slurred, # of words per sentence, etc. facial droop? some of these are positive or negative findings but document your assessment.
[CHEST] chest pain? SOB? Lung Sounds-->describe them. equal chest expansion?
[ABDOMEN] soft? tender? distended? pulsating mass? etc...
[PELVIS] stable?
[BACK] DCAPBTLS?
[EXTREMITIES] PMS x4? x3? amputation? edema?
[SKIN] temp? color? moisture?

then my Treatment section. what did I do. O2? ECG? Glucose? SPO2? meds? etc.

If I gave meds an Rx section

then a changes section

at last but not least the transport section-->how did we transfer the Pt. position of Pt. where we went. etc.

I know reports are lengthy but I try to put in my report as much as possible. This way a MD can find out exactly how the Pt was when we found them. because many times I am no longer around when the MD sees a Pt.
I also tried to be this detailed if I ever need to recall anything for court.

If anyone has any suggestions, I am more than happy to use new things to make my reports even better