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Field Notes Forms


cfaulknor

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I use just regular plain notepads-- I get em in packages of 6 or so for a couple bucks at CVS. Usually this is the limit of what I write down:

asses1s.jpg

Unless it is a complex complaint or a large list of answered questions, I am usually able to remember answers to the assessment questions long enough to give a report and write a run form. If I need to write more, I just flip the page over and scribble some more notes.

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You kind of have to decide what you are going to use this notepad for. Are you going to write everything except your narrative on there, as Fiznat has done? Just VS and key points that stand out to you? Are you going to use it as a poor man's field guide to remind you of quetions to ask the patient? Most people, I would venture, who write anything down on note pads/gloves/tape, only write down those few things you need handy for phoning in your report to the E.R. All those PQRST, DCAPBTLS, ABCDE, etc... things you should be committing to memory, because that's where they are most important, not on paper. I see too many n00bs get all caught up in asking questions, writing down the answers, but never actually processing that information in their brains. They ask all the right questions, but they're just going through the motions. That is the key to functioning competently as a paramedic. If you are actually listening to and analysing the answers your patient gives you, you won't have any trouble remembering it for the PCR.

And speaking of PCRs, this is one thing that sucks about electronic run reports. Paperless my arse! You are STILL writing everything down! The only difference is now you have to write it down AND type it instead of just writing it down once and being done with it. We hardly had to use note pads at all back in the paper PCR days. All the demographic info, VS, meds and allergies, etc... was being jotted down directly onto the PCR as the patient provided it. Everything else, you just remember. The only things we had to write down on a pad or our glove or knee was repeat VS and event times.

Anyhow, there really is no real set-in-stone format for these things. You are right on to make up your own in a way that suits your needs. And your needs will change rapidly as you gain experience. You'd be amazed at how little most really experienced medics write down on a scene. I could just about get all the way to the hospital without even needing a pen on most patients.

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You kind of have to decide what you are going to use this notepad for. Are you going to write everything except your narrative on there, as Fiznat has done? Just VS and key points that stand out to you? Are you going to use it as a poor man's field guide to remind you of quetions to ask the patient?

Dust makes a good point here, but one thing that I found from my experience is that when I first started in the field as a student I was using my notepad as a "poor man's field guide" and would have "OPQRST" or other small prompts written down on it. As I did more calls though it became much easier to remember the details and I found that I would just write down things that stood out.

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I'm wondering how you guys set up your forms for patient assessment, specifically the ones you guys use to write while you're on the go.

For writing "on the go", I prefer free-form. A lot of things I keep in my head, but when I need to write something down, then I want to get it written and worry about organizing it later. It's too hard to talk to a patient, get answers, try to write those answers into the right slots on a form, or to check the right boxes on a form, all while still processing what the patient is telling me. With a free form notepad, I can better pay attention to the patient. Plus, there's no large clipboard between us, and that helps too.

What I do then, is to carry a small and inexpensive, spiral, pocket notebook. I jot notes in that -- usually just vital signs and times, but sometimes allergies, street addresses, whatever else I might need to track that I fear not being able to commit to memory.

What I do works well for me. I don't promote it as the "one, true way".

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