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jaymarico

Writing better narratives

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So, I'm a year into being an EMT and I feel like I've at least started to settle into a narrative style that works for me. But, I'm always looking to do better. Recently, I've wondered if there are any books out there or just personal experience that could help me. The main thing I'm looking for would be sentence structure and word choice. What helps you break down your call and how do you create a story of what happened so that the person reading gets the full picture?

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Posted (edited)

Well I'm not sure how my new job will want my narrative.  It's been 9 years since I wrote one and I'm getting back into the swing of things starting May 15th.  

 

But my reports when I used to write them were hand written on a paper report form.  yeah, it was before computers got in our way of writing reports and before we had to tick off all those legal mumbo jumbo boxes to make the bean counters happy.  So I'll give you a idea of what my narrative was like. Remember this was a long time ago so I'm sure others have better ways of doing things now.  But I can tell you, my narratives never pulled me into court.  

1st paragraph - What happened - why you were called, what you found, what bystanders said, what patient said, what you observed.  etc

patient exam/assessment - the formatting of this site makes it hard to put it all down line by line but here goes

Heent(head, ears, eyes, nose, throat); Neck; Chest; Lungs; Heart; Back; Abdomen; Pelvis; Gi/GU; Extrems; Neuro/GCS/RTS/  (all of these go on their own lines with what your exam findings are)

What is your Impression/Impact -  what did you really decide is wrong with this patient - they say we don't diagnose but we really do.  So don't be afraid to say if they are having chest pain to say chest pain or if their 12 lead shows elevation in II, III and AVF to say that.  What is your impression or suspicions.  

And now your treatment - Number them sequentially - from when you got there to when you dropped them off at the hospital - make sure you put down if they got better or if they got worse.  Don't be afraid to say that if your treatment made them worse - say it because sometimes your treatments make them worse.  Sometimes your treatment like Synchronize cardioversion causes them to go into v-fib.  that makes them worse.  Or you give them Lidocaine to a paced rhythm (honestly I didn't see the pacer spikes- really i didnt' and you nearly code them) put that in the report.  (man I felt like crap on that one - but I was a brand new medic and I learn from my mistakes and teach from those mistakes).  

That's all I got.  

 

Oh yeah there's one more thing - there is a very obscure book out there,  if you can find it, buy it and never let it go - I did and the person lost it.  It's called "The Missing Protocol-A Legally Defensible Report" by Denise Graham It doesn't tell you how to write a report but it does tell you how to write a report that will keep you out of court if you do it correctly.  It's out of print so I'm not sure if you can find it,  I haven't been able to find it.  May the person who lost my copy be crapped upon by a thousand camels with IBS and C-diff.  

 

I hope this helped. 

Edited by Just Plain Ruff

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