Writing reports as paramedic

[joshrunkle35]

Depth of your assessment will come with being really good at your paramedic skills, especially the medical portion, and then the documenting portion just follows the way you think.

Let's say you get called to an Altered Mental Status patient. So, right off the bat, you should know, it could be a blood sugar issue, a psychological issue, a drugs or alcohol issue, a UTI in the elderly, a possible head injury, a possible stroke or some other chemical imbalance/toxin. The doctor or nurse reading your report/chart are going to be thinking the same things, and since you may be first on scene, you are the first real medical person to give an initial impression and assessment. This may form a crucial baseline or history for the future of this patient. The goal of your chart/report is not to say odd things that stand out, it is to show what has been checked and evaluated at that time.

For example, if your patient isn't stumbling as they walk, you might not think right now to note it. But let's say that an hour later they start stumbling. The doctor won't know whether they were stumbling and you forgot to note it, or they were stumbling and you didn't notice it, or if the patient is getting worse because they weren't stumbling earlier, but now they are. But, if a doctor can read, "No ataxia or unusual gait or awkward movements noted at this time" at 1400 and it's now 1600 and the patient now has ataxia, well, that gives the doctor a major clue that this patient may be getting worse. Pertinent negatives are just as important as pertinent positives.

In my example of an altered mental status, you should do every evaluation for all of those possibilities, until you have significant information, like a patient tells you that they have diabetes, they left their insulin pump at home and your glucometer reads "HI", or they specifically tell you that they just took recreational drugs, etc...

 

[Ewok Jerky]

If it is that bad you should be using a template. Get one from school, your preceptor or on line. Don't cut corners, do a full HPI (history of present illness) and a full H&P (history and physical) on every patient until you hone your spidey senses. Ask and document a review/physical for every system every time (general impression, skin, respiratory, cardiac, GI, musculoskeletal, neuro, behavioral, endocrine, and if appropriate ENT, hematologic, genitourinary)

 

[Ewok Jerky]

Also SOAP is a very easy format once you understand it for your narrative.

SUBJECTIVE: Everything you hear or are told including what family tells you, what the patient tells you, and what bystanders tell you. This includes answers to your OBQRST and other subjective questions . Think of this as everything that could be put in quotations.

OBJECTIVE: Facts. Things you see, things you find, things you observe such as physical exam, information from medical records, labs, Etc. Response to treatment can go here in EMS setting.

ASSESSMENT: what is your working diagnosis or differential?

PLAN: what are you going to do (treatment, transport decision).

 

[Bullets]

I don't chart things that don't happen. Only what happened, only what the patient tells me or I can see or assess. I don't understand why period put things like negative chest pain, sob, Neuro defects ect. As far as I'm concerned, a blank chart with just demographics is a perfectly healthy normal human, I then document the areas in which the patient stays from normal. But that's how our system has progressed. We're changing charting systems so I'm sure that will change

 

[Ewok Jerky]

I don't chart things that don't happen. Only what happened, only what the patient tells me or I can see or assess. I don't understand why period put things like negative chest pain, sob, Neuro defects ect. As far as I'm concerned, a blank chart with just demographics is a perfectly healthy normal human

You don't document pertinent negatives? So your patient complaining of SOB could be COPD, asthma, MI, PE, anxiety, PNA etc...
Documenting pertinent negatives is crucial to crossing things off your differential.

A blank chart to me is useless because I don't know what you asked about or any of your physical findings. It doesn't indicate a normal human it indicates a lazy provider.

 

[Bullets]

You don't document pertinent negatives? So your patient complaining of SOB could be COPD, asthma, MI, PE, anxiety, PNA etc...
Documenting pertinent negatives is crucial to crossing things off your differential.

A blank chart to me is useless because I don't know what you asked about or any of your physical findings. It doesn't indicate a normal human it indicates a lazy provider.

Physical findings would be things i asses, so they would be documented. Which I said i already do. Which of those conditions you mentioned dont have other clinical signs we can measure or note?

Why would you say its not copd, asthma, mi, just say what it is?

 

[Handsome Robb]

Physical findings would be things i asses, so they would be documented. Which I said i already do. Which of those conditions you mentioned dont have other clinical signs we can measure or note?

Why would you say its not copd, asthma, mi, just say what it is?

Because, especially at the BLS level, you cannot say that. As a paramedic if my monitor shows a STEMI I'm going to call it that but I'm still going to list pertinent negatives that I asked about. You need to be asking these questions because people don't always know what to offer up as information unless asked.

EMS personnel do diagnose, I'm not saying we don't form a working diagnosis but if your charts are just saying, "The patient is experiencing a CHF exacerbation" then your assessment findings you're not performing a good enough subjective assessment. Yea subjective isn't always accurate but it needs to be documented. Now if the patient has a single complaint and adamantly denies any other symptoms then that is exactly what I document. "The patient complains of retrosternal chest "pressure" radiating into his left jaw and shoulder. The patient adamantly denies any other associated complaints".

PCRs are a legal document and need to be thorough, otherwise you're (not you specifically, generalized 'you') are going to look real dumb when your chart is blown up on a huge screen in front of a court room and you didn't document well enough.

 

[Ewok Jerky]

Physical findings would be things i asses, so they would be documented. Which I said i already do.

Part of "clinical signs we can measure or note" includes asking and documenting about associated conditions to make sure we are covering our bases. When I have a 75 y/o F who appears dehydrated and just started HTCZ and feels dizzy, I don't just write "orthostatic hypotension", I also ask about chest pain, nausea, SOB etc to rule out MI. When I have an obese 55 y/o M with chest pain after golfing, I ask about hx of GERD and diet/last meal type questions to consider other sources of chest pain/discomfort. I am not knocking your clinical skills but your documentation and verbal reports will rock if you include these pertitent negatives.

I also forgot to mention the importance of pertinent negatives for reassessment and trending a patients condition. The obvious examples are evolving cardiovascular events like stroke and MI, but you can also imagine response to treatment or more likely decompensation despite treatment.