Patient care reports

[musicislife]

What do you guys put in the narrative section? It seems that when I write a report, I cannot fit everything into the narrative section, even for simple calls. Any ideas?

[MariB]

Your service should have an extra piece of paper to attach to the back for additional information??? We do on our paper ones. However we only use paper for back up.

Let's give an example of mine... let's say a kid fell off a bike and hurt his arm.

mari dispatched 911 for a child who fell off his bike.

Upon Maris arrival EMTs found a 9 year old male laying supine on a residential sidewalk being attended to by mother. Child's faces was red, eyes swollen from crying, no noticeable injury to face.

When asked what happened child stated "I fell off my bike and hit my knee " Child is noticeable favoring right knee. Permission to treat grated by mother. Patient denies any pain in c spine. No c collar applied. Vital signs taken and noted .

Patients pants are cut from the ankle to the hip to look for any signs of wounds, tenderness or deformities. Some redness and swelling is noted below the right patella. Rigid splint applied.

Patient lifted to cot via two EMTs . Voids are padded with pillows. Ice was not applied as child would cry every time knee was touched. Head of bed elevated for patient comfort.

Mother accompanied child enroute sitting seat belted into captains chair.

Detailed exam did not reveal any other injuries.

No other changes enroute.

Care transferred to Kristy RN at Made up Hospital.

Bare with me, I'm on my phone so it isn't perfect. I'm not comfortable with abbreviations yet so I don't use them and I've only don't a few pcrs so far. I'm still new. We do ours on computer so all our vitals, history and everything else has its own place

And mind you, unless on a transfer, our enroute time is like 3 minutes. I also would have stated loaded into ambulance. But yeah. I read mine like 5 times before putting it in. Now if my patient had fallen a long ways. . It would have been much longer of a report. Hand grips, rapid trauma assessment, back boarding, log rolling. Etc.

[Ukmedic2013]

Tend to follow the pattern of: Allergies Medication Past medical hx Last meal eaten Presenting complaint History of presenting complaint On examination Treatment Clinical impression

[scubanurse]

CHART

C-chief complaint...i.e. what's going to kill them first and why they called 911

H-SAMPLE

A-subjective and objective assessment of the patient

R-treatments/protocol you followed

T-transport...how they were transported (cot, ambulating, backboard, restraints, etc).

[Arctickat]

S-Subjective Observations

O-Objective Observations

A-Assessment

P-Plan for treatment

[MariB]

Noe for those of us with laptops all that stuff gets put in a different spot. With paper reports, isn't there a special spot for all the allergies, medications etc? When we print, it prints out right above the narrative. So we do not add that. I know the one and only paper one I filled out there was a separate place for all their meds. Allergies. Vitals, history etc. So it was not to be included in the narrative.

I was told the narrative is a picture in words of what we saw and what we did. The other stuff is charted elsewhere

[HarryM]

Our patient report forms are split into 4 sections:

1. Details relating to the job such as job times, job number, vehicle number, date, inital patient status and patient status at ED

2. Patient personal details and chief complaint

3. About 1/4 of an A4 page for you to write job details

4. Drugs and interventions section where there is space for RR, HR, BP, GCS, BGL, Temp, Pain

For my written section in 3 I usually do history of what happened prior to ambulance being called. Initial patient assessment on arrival. In-depth examination findings including provisional diagnosis and pertinent negatives. Any changes to patient enroute or post-interventions/drugs. If I leave them at home I write what the patient was advised to do by me and that patient was told to call am ambulance again if significant deterioration occurs. I can usually fit it into the space given. You get better with time and experience with writing succint reports that still cover everything you need them to.

[craig]

IMIST AMBO

TRAUMA. MEDICAL.

Identification Identification

(Pt's name & age etc.)

Mechanism of injury Medical complaint

Injuries. Information relative to complaint

Signs & symptoms. Signs & symptoms

Treatments & trends. Treatments & trends

Allergies. Allergies

Medications. Medications

Background. Background

Other issues. Other issues

[chbare]

We use the DCHART format:

D: Dispatch information

C: Chief complaint

H: History (SAMPLE & OPQRST)

A: Assessment: Physical exam, Labs & Vital Signs

R: Rx: Treatment rendered and patient response

T: Significant notes during transport

Field impression at the end

I have copied a fairly recent PCR that I did with some of the data removed or changed for obvious reasons:

D: Dispatched to the scene of a 76 year old male or female with weakness

C: 84 y/o male or female found sitting in chair at home with family at his/her side, pt reports “I think I feel alright,” family reports he/she has been very weak and breathing fast and they cannot get him/her out of his/her chair to get into the car to take him/her to the hospital, Pt contact made at 09:50

H: S: generalized weakness, tachypnoea

A: NKA/NKDA

M: Jalyn 0.5 mg PO q D, Megase oral PO Q day, mirtazapine 7.5 mg PO Q day, tamsuiosin 0.4 mg PO Q HS, temazepam 30 mg PO Q HS, Trazadone 50 mg PO Q HS, hydrocodone/APAP 5/325 PO PRN, lisinopril 1.25 mg PO Q D

PmHx: HTN, BPH, Fall resulting in intracranial haemorrhage in December 2012

L: Last HS

E: Family reports that the patient has recently been discharged from rehab following a fall resulting in a TBI but has been progressively weak and unable to perform ADS’s with s/s that have worsened over the past couple of days

O: Last HS

P: Denies pain or discomfort

Q: Denies pain or discomfort

R: Denies pain or discomfort

S: Denies pain or discomfort

T: As defined above

A: HEENT: Sitting upright in chair, AO times 4 with movement in all extremities, atraumatic to exam, airway patent and self maintained with increased respiratory rate, pupils pinpoint and minimally reactive bilaterally, neck midline with flat jugular veins, Pt able to swallow without difficulty and smile w/o indication of facial droop, speech slow but non-slurred

Cx: Atraumatic, unlaboured respirations, no accessory muscle use, clear lung sounds in all lobes, no c/o dyspnoea, no overt s/s of respiratory distress, but rapid and deep respirations at a rate of 24 noted with regular rhythm, irregular, faint heart tones noted at an elevated rate of 112-118, firm, round mass with a diameter of approximately 5 cm noted to lower right anterior chest wall, Pt reports “I have had that forever”

Abd: Soft all quadrants, non tender to palpate, atraumatic to exam

Pelvis/GU: Pelvis stable and intact, full GU exam deferred, Pt reports that he/she has been having “difficulty going pee”

Ext: Movement in all extremities with weak bilateral hand-grips, atraumatic to exam, pale/cool/dry skin with decreased turgor, no indications of cyanosis or jaundice noted

Neck/Back: Atraumatic, midline w/o step offs, Pt denies any c/o

V/S: B/P- 60/40, P-118 & irregular, RR- 24 w/o overt indications of significant respiratory distress, SpO2-88% R/A, T-98 F, Wt~68 kg, Temp 97.1 F tympanic

Rx: 1) Pt contact and full assessment, placed on portable pulse oximeter and BGL of 265 mg/dl noted, Pt placed on supplemental Oxygen at 2 L/min via nasal cannula @ 09:50

2) Pt carried out of his/her room and down a small hallway via transfer sheet and placed onto the EMS str into semi Fowlers position by EMS crew, Pt reports “feeling like I’m going to faint” upon being picked up, Pt properly secured onto EMS str w/o incident @ 09:55

3) Loaded and properly secured in EMS unit for transport w/o incident, Placed on monitor for continuous SPO2 monitoring and cardiac monitoring in lead II with q 5 min v/s reassessments and XII lead acquisition and transmission to General Hospital ER w/o incident, sinus tachycardia with frequent unifocal PVC’s w/o overt ST changes or indications of BBB noted @ 10:00

4) 20 ga IV placed to L AC times one attempt using aseptic technique w/o incident along with BGL check (123 mg/dl), fluids up at 1,000 ml 0.9% NS at wide open rate for volume expansion @ 10:02

5) Radio report called to General Hospital ER w/o incident @ 10:05

6) Discussed possibility of Zofran administration for c/o nausea with EMS preceptor; however, she/he does not want to administer it at this time d/t "short ETA to the hospital", Repeat VS reassessment @ 10:10: B/P- 72/40, RR-22-24 and non-laboured, SPO2-96% 2 L NC, P-112 irregular, lung sounds remain clear after 500 ml of fluids have been administered, 1,000 ml challenge continued

T: Pt transported to General Hospital ER w/o incident or change in assessment or condition, bedside report and turnover to Dr Smith w/o incident @ 10:15

DDx:

1) Hypotension with possible tissue hypoperfusion

a) Possible infectious pathology (Consider urinary and respiratory sources as high priority systems to assess)

Possible toxicological etiology (Consider opiate toxicity with possible poly-pharmacy as a primary candidate)

2) Cannot rule out neurological event (TIA vs Stroke with possible increased ICP or intracranial mass effect)

3) Possible fluid volume deficit

4) Hypoxaemia with possible tissue hypoxia

5) Hypoglycaemia R/O with point of care BGL testing

Please note this may be based on a patient encounter but it is not an actual chart and presented here as a training tool.

[HarryM]

mari dispatched 911 for a child who fell off his bike.

Upon Maris arrival EMTs found a 9 year old male laying supine on a residential sidewalk being attended to by mother. Child's faces was red, eyes swollen from crying, no noticeable injury to face.

When asked what happened child stated "I fell off my bike and hit my knee " Child is noticeable favoring right knee. Permission to treat grated by mother. Patient denies any pain in c spine. No c collar applied. Vital signs taken and noted .

Patients pants are cut from the ankle to the hip to look for any signs of wounds, tenderness or deformities. Some redness and swelling is noted below the right patella. Rigid splint applied.

Patient lifted to cot via two EMTs . Voids are padded with pillows. Ice was not applied as child would cry every time knee was touched. Head of bed elevated for patient comfort.

Mother accompanied child enroute sitting seat belted into captains chair.

Detailed exam did not reveal any other injuries.

No other changes enroute.

Care transferred to Kristy RN at Made up Hospital.

Interesting to see how different people write out reports and great to pick up some tips and tricks from other.. My version of this is:

"History of fall off bicycle at slow speed landing on R) knee. Ambulance called,

O/A: pt supine on footpath -> conscious & alert ->good colour -> in obvious distress

O/E: primary survey clear. Secondary survey reveals R) knee injury with nil signs of knee or patella dislocation or obvious fracture. Redness and swelling present. Pt very distressed with knee examination. Unable to determine FROM. ? soft tissue injury. Pain 5/10. Splint applied. Pt has nil other injuries. C-spine cleared. Pt has full recall of events and nil neurological deficits. Nil pmhx.

E/R: pt pain decreased with pain relief and reassurance and pt become more relaxed. Nil change in pt condition.

Meds: Nil

Allergies: NKDA"