Assessment and Documentation Critiques

[sowenstech]

I'll start this by giving you a rundown of how I narrated my PCR for this particular patient.

Service and Unit # Pvt dispatch to Address for __ y/o sex with C/C ESRD to be

Tx to Facility for Rx of life-sustaining hemodialysis. Upon arrival, Pt presents with no

distress. Pt denies any CP, SOB, N/V. Pt KDA to ____, Meds as follows:**list**, PMHx DM, HD, HTN,

COPD, CVA, ESRD, PAD, PVD, Anemia. Pt last PO @ 0630. C/C 2º to DM, HTN.

Pt lift x2 crew to stretcher, left lateral recumbent (cva) x3 straps. Vitals above, assessment

enroute. HEENT normocephalic, Perrl @ 3mm, no JVD, chest rise/fall=, lungs c+e x2 upper fields,

diminished x2 lower 2º COPD. ABD soft, N/T x4 quads. Pulse + x4 ext with = grip strength. M/S

+ R side, diminished L side 2º CVA. Pt presents with A/V cath R subclavian. No other DCAPBTLS.

Pt admin O2 4lpm NC per PCP Rx COPD, monitored enroute, vitals q5 min, continuing assessment

and care PRN. Tx to Facility uneventful with no other C/C or incident enroute. Report and Pt

care transferred to LPN, RN, MD, DO, etc

My so called "supervisor" said that my narrative was to Medical Sounding and that

I shouldn't use such big words. I don't need to fill out the entire narrative box. I use too many

shortcuts, etc. I was also informed that assessing JVD was not an issue on a routine

dialysis Tx. First of all, I use medical terminology to the best of my abilities because....I WORK IN THE

MEDICAL FIELD!! I feel that everything I put in my narrative is important. Since BP and Kidneys

do go hand-in-hand, a presentation of JVD alongside a normal brachial BP reading may indicate some

type of shunting. I've seen it. A/V cath or fistula placement is neccessary for another provider if the pt

were turned over to an unfamiliar crew, ALS, etc. A transport is NEVER just a transport. I am just fuming

right now over this! :evil: :evil: :evil: . I recently had an ER Physician tell me I wrote a very informative

PCS. I document everything I see, do, find, what is pertinent to the C/C, pertinent negatives, etc.

I document according to C/C and what I see. MVC? I look for all of the above plus CS fluid, bleeding from

orfices, priapism in males, musculoskeletal injury or deviation, etc. the list could go on forever.

So tell me what you guys think. Is there such a thing as overdocumenting. My personal opinion

is that if you assess, document, Rx, and reassess, then you've given your patient the best care you can

provide.

[mobey]

I'll start this by giving you a rundown of how I narrated my PCR for this particular patient.

Service and Unit # Pvt dispatch to Address for __ y/o sex with C/C ESRD to be

Tx to Facility for Rx of life-sustaining hemodialysis. Upon arrival, Pt presents with no

distress. Pt denies any CP, SOB, N/V. Pt KDA to ____, Meds as follows:**list**, PMHx DM, HD, HTN,

COPD, CVA, ESRD, PAD, PVD, Anemia. Pt last PO @ 0630. C/C 2º to DM, HTN.

Pt lift x2 crew to stretcher, left lateral recumbent (cva) x3 straps. Vitals above, assessment

enroute. HEENT normocephalic, Perrl @ 3mm, no JVD, chest rise/fall=, lungs c+e x2 upper fields,

diminished x2 lower 2º COPD. ABD soft, N/T x4 quads. Pulse + x4 ext with = grip strength. M/S

+ R side, diminished L side 2º CVA. Pt presents with A/V cath R subclavian. No other DCAPBTLS.

Pt admin O2 4lpm NC per PCP Rx COPD, monitored enroute, vitals q5 min, continuing assessment

and care PRN. Tx to Facility uneventful with no other C/C or incident enroute. Report and Pt

care transferred to LPN, RN, MD, DO, etc

If you remove the double spacing it is not that long at all..... in fact it may be a little short for some.

Your supervisor sounds like he has never been to court, keep doing what your doing.

You may be called into court on some case you did over a year ago, your PCR may be all you have to go on!

[sowenstech]

The PCR here in WV has a relatively small space for the narrative. I also shortend it for spacing issues in the post. I do appreciate your comments however. I will post a complete narrative momentarily so as to give a better idea. I'm still fairly new, only six years in, so all criticism is welcome.

[letmesleep]

I can only speak on the Missouri "PCR" called a MARF or MARS (Missouri Ambulance Reporting Form or Sheet). This issue is one of my BIGGEST gripes in regards to any type of administration. Your PCR is YOUR documentation of a Pt within YOUR care and should be written the way YOU feel comfortable. If you choose to fill out 14 pages of continuation forms to document your Pt care with a single Pt, or write 1 sentence it is up to you. I know that a lot hinges on the PCR, but in all reality it is YOU that is going to answer for what is written.

Everything you write can support you and harm you, but that should and is YOUR decision, not your administrators.

end rant.........................

[JakeEMTP]

Before we joined the electronic age, we had a completely separate form for the narrative portion of a PCR. We/I were/was free to use as many of these forms as required to document what we/I thought was necessary. Now that we have the ePCRs', the room for a narrative is endless.

I cannot fathom a supervisor saying you had too much information in your narrative. If it was redundant, then maybe, but from what you posted it all seems relevant. Keep up the good work.

[sowenstech]

Ok, here is a detailed PCR of probably the most interesting call I've had in a couple years. The back story: Male tries to kill himself by eating 40 Oxycodone 7.5mg, washing it down with a bottle of Phenergan with Codeine, chased with a fifth of Wild Turkey. Pts girlfriend is related to an EMT in neighboring county. She contacts a co-worker, informs them they will be getting called for ALS backup, so they are enroute before tones drop. My partner and I are the unfortunate souls who fall victim to the following. All names, hospitals, and agencies are changed to protect the innocent, and the stupid.

BLS unit 01 911 dispatch to Mtn Rd for 42 y/o male unconscious/unresponsive. Upon arrival, pt found lying supine in front yard, unresponsive. Pt presents with dyspnea, diaphoresis. Family states attempted suicide. Family provides empty med containers, filled same day, and empty liquor bottle. Pt NKDA, no meds, PMHx HTN, Bipolar disorder. PO intake at 1700. Vitals as follows: HR 140, Resp 3, BP 60 palp, GCS 1/1/1, Skin pale/diaphoretic, Pupils NRL/constricted. HEENT normocephalic, no blood/cs fluid present. Trach midline, no JVD, chest rise/fall=, lungs diminished all fields with dyspnea. ABD soft x4 quads. Pulse + x4 ext. no DCAPBTLS. Pt manual ventilation BVM/O2 15lpm, nasal airway size xat 1722, log roll to longboard shows no posterior DCAPBTLS. AED electrodes in place. Pt secured to longboard, stretcher x3 straps, trendelenburg. Contact control, ALS requested. Continue Ventilations enroute, vitals q 3-5 min. ALS intercept @ 1727, County ALS 02. Medic Doe boarded BLS unit 01. Continue assist ventilations, other interventions at Medic Doe request. 1735 pt fiancee, passenger seat, vomit x2, syncople x3. Passenger sudden onset CP,SOB,N/V. pale diaphoretic. C/C crushing substernal pain, non-repeatable on palp, radiating to L arm, 8-10 on pain scale. O2 12lpm NRB, ASA 81mg (x4)PO, NTG x1 SL per Medic Doe. Contact control, request second ALS unit. Intercept County ALS 01 @ 1740. Passenger transferred to County ALS 01. Male Pt vitals stable, 2 Narcan IV per MCP. Pt C/A/O x3 upon arrival to County ED. Report and care to County ED RN Jane Doe.

Evidently, one of the volly FD first responders told her to go ahead and ride along with us. Could've been helpful for info purposes, provided she wasn't high at the time! So while the Medic and I deal with an OD, she passes out thrice, then has an MI in the front seat! Good times....Good times.

EDIT**

Forget to add that I referenced the medics PCR # on my PCR, so as to continue the flow of treatment and information from BLS to ALS.

[becksdad]

Agreed you did a good job not only assessing, but documenting. I will always maintain that good assessment and interpretation of findings is the whole basis for good patient care. Documentatation supports anything you did or did not do. So I don't get your Stuporvisors problem........

Big words? Too medical sounding? Perhaps they could provide some paper documents with the really WIDE lines and some big, fat crayons to write with.

[Eydawn]

Oh my *GOD* I feel your pain. At the job I just left (CNA-type care for adults with developmental disabilities... definitely a lot of medical) I had my supervisors give me the same gripe about my incident reports which we used to document client injuries and illnesses etc....

Apparently I use too much medical terminology, too many big words, and parents and case managers don't understand what I'm talking about. Hello? I thought I was *supposed* to be smarter than my clients...

Also, I'm too blunt and apparently, via an anonymous complaint that refuses to give itself a face and hides behind performance evals, rude to supervisors. That, among other reasons, is why I left. Apparently it never occurred to their lawyers that allowing me to use my EMT-B in lieu of a First Aid card meant that I needed to document to my level of training in case something ever came up in front of the state... because you *know* some pissy guardian's lawyer is going to zero in on that one little thing...

But I digress. Suffice it to say, I know where you're coming from with that critique...

As far as your documentation goes, it seems perfectly fine to me. I personally don't dig abbreviations except the really really obvious ones, like IDDM, HTN, COPD and O2... because Tx might mean transfer or treatment, etc. I generally try to use plain English as much as possible and paint a picture, which you seem to have done very well. If I can't paint the picture so that I can see it myself after being away from it for several months, it isn't documented well enough. I also hate check-box PCRs... even though they are technically adequate, I prefer the flexibility of the narrative. I think you're doing exactly what you should be doing, supervisor or no.

Wendy

CO EMT-B

[CBEMT]

Emergency call patient? absolutely, give em a good assessment and write it all. Four years of dialysis transports, I can't say I ever felt the need to shine lights in patient's eyes, or take q5 vitals on stable people. Basic school anybody?

95% of my dialysis patients were uncomfortable enough as it is. I don't think I need to be poking and prodding people going through an experience I wouldn't wish on anybody.

[JPINFV]

A/Ox4 dialysis patient more often than not have the following V/S and narrative entry.

RR: 16, Pulse: UTO, B/P: UTO. Pulse/BP UTO per patient request/patient comfort. There have been plenty of transports where the patient requested, with no prompt, to not have their v/s taken.