Sample patient narratives

LanceCorpsman

LanceCorpsman

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Im still fairly a noobie, i am having some issues with my documentations. I use the SOAP format. I just want to see some examples of experienced prehospital providers charts. Can anybody post like a sample or something please?

Im having an issue with going too in depth and my charts tend to get a little too long...
 
Good luck getting a narrative out of me. Simply put: there's a million ways to skin a cat.

I used to tell my trainees "Beginning. Middle. End." What did you do/ see/ find in the beginning, middle, and end of the call?

It's a simple and straightforward way to "paint a picture" as I used to like to describe it. If your instincts are telling you to put it in your report, chances are it's pertinent. It gets easier over time.

Just wait until you're depo-ed:). It actually helps tailor your narratives as well; least it has mine.
 
I personally prefer a more chronological narrative. We found this patient, complaining of this, presenting with these symptoms, we found these signs, pertinent posititves and negatives, treatment rendered, transported to which hospital and any changes enroute.
 
Most agencies have specific documentation guidelines. (I've never worked at one that hasnt) I'd check with your training officer.
 
LanceCorpsman said:
Im still fairly a noobie, i am having some issues with my documentations. I use the SOAP format. I just want to see some examples of experienced prehospital providers charts. Can anybody post like a sample or something please?

Im having an issue with going too in depth and my charts tend to get a little too long...
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What is pertinent subjective information will be pretty patient dependent.

My objective is the physical exam (Skin, HEENT, Chest, Abdomen, Back, Pelvis, Extremities), a Mental Status Exam, and Neuro Assessment (pick your flavor). I write only what I find, unless a pertinent negative is related to a complaint (IE, the neck pain pt who doesn't have crepitus or pain on Range of Movement).

The plan is pretty quick. What was done on scene, how was the patient moved, how were they secured to the cot, and what was done during transport. It's very general (IV access, Zofran with good antiemetic effect). I try to document a response treatments. Then how the patient was moved to the hospital bed and who the patient was left with.
 
Jim37F said:
I personally prefer a more chronological narrative. We found this patient, complaining of this, presenting with these symptoms, we found these signs, pertinent posititves and negatives, treatment rendered, transported to which hospital and any changes enroute.
Click to expand...
This right here. I have never liked SOAP or CHART. Just tell a story, beginning to end. Include all that is not noted elswhere in the report. I like anyone to be able to read a report and understand what happened in call.

I have never and will never work for an agency that mandates how I write my reports. These are records in your name, not theirs. Some software like emscharts, really does not require much narratives. Just be thorough and not too long.

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Dispatched to (type of location) for a complaint of (dispatch complaint, usually wrong).

Arrived to find (number) year old (gender)(position and location found in). Pt presents CAOx4. Pt complains of (patients actual stated complaint).(also included here would be statements from witnesses, facility staff, the engine company if they got their first and heard/did things, the police etc).

Physical exam and ROS:

Const: Denies recent illness or trauma, sick contacts, surgery, changes in diet or sleep patterns.
HEENT: CN II III IV VI intact, airway patent, trachea midline, no JVD appreciated. Denies headache, vision changes, pain throughout field.
Cardiovascular: Denies chest pain, SOB, edema, palpitations.
Respiratory: Lungs CTA x 5 with equal rise and fall. Denies cough, sputum, wheezing, hemoptysis.
GI: Abd soft non tender non distended without palpable masses. Denies ABD pain, indigestion, cramping, nausea, vomiting, hematemesis, hematochezia, melena.
Integ: Pink, warm, dry, appears grossly intact. Denies rash, lesions, wounds, incisions, pain.
Neuro: Grossly normal exam. Denies recent sensory changes, paresthesias, weakness, gait disturbance.

Pt transferred to stretcher, secured x 5 straps, siderails up, loaded into ambulance without incident.

Cardiac monitor applied, (rhythm) at a rate of(#) w/wo ectopy . IV access established(#) g x(#) attempt, Nacl lock.

En route: Pt monitored. V/S as noted. Pt remained stable and without change to condition.

Upon Arrival: Pt transferred to bed. Care transferred to staff with rpt.

\end RPT.

Obviously thats missing any actual acute findings, complaints and treatments, but thats the broad strokes. It generally follows a chronological format. Interspersed in there would be treatments as they occurred. For example if I did a 12ld in the house, that would naturally come before the extrication phase etc.
 
I use the following:

PMHx
SHx/FHx as required
HPI (as appropriate)
Now/complaint
On arrival:
On exam:
Diagnosis:
Referral/plan:

If the patient is transported somewhere by ambulance then under referral I'd add "enroute" and add a brief summary of what happened; if nothing then simply write "no change".

In ePRF all of the treatment and vital signs stuff goes in another section.
 
Just tell it like a story. Dispatched to this. Arrived to pt. in this condition. Assessed vitals and determined this. Rendered this treatment...etc.
 
C: Call (super basic description of what you found)
H: History (Everything that happened before you started doing stuff)
A: Assessment (What you found)
R: Rx (What did you do for them)
T: Transport (Where, and how fast, you took them)

M56 arrived at scene to find pt seated on bed in bedroom of residence, in no apparent pain or respiratory distress, under care of BAFD and c/o abd pain and vomiting x 12 hours.

Pt states that she woke up with low grade abd pain and mild nausea, both of which have increased in severity throughout the day; pt has vomited 3x in past 5 hours (normal stomach contents) and has developed a low-grade headache. Pt has taken OTC medications (Dayquil, Advil) and attempted to rest with no relief. Pt States that she has had several (3+) similar episodes in the past 4 months but none have lasted this long. Pt states that she has experienced "a few" episodes of dizziness when she has gotten up from bed. Pt denies CP, SOB, diarrhea, diaphoresis, double vision, photophobia or recent trauma. Pt is post-menopausal and denies any pain or changes to/during urination.

Assessment revealed pt to be tachycardic and warm to touch but otherwise unremarkable. Pt neurosensory function intact with no obvious signs of outward trauma. Pt BGL, 12L and CPSS normal.

Pt vitals monitored en route, IV access established and fluids administered with improvement to HR. Pt nausea improved post administration of IV Zofran. Pt refused pain medication.

Pt transported C2 to SMC, report given and care transferred to RN without incident.
 
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