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Dominion
04-18-2010, 09:49 PM
Ok I know this is kinda dead horse territory but I wanted to get some other opinions and not just those who I work with. I've had my first couple full arrests as a paramedic rider and while both were not only my first as a paramedic but were my firsts...period (both were ROSC and are in ICU still). Anyways I've written two different narratives, trying two different styles (these are for class). Could I get some advice on writing a narrative for cardiac arrests?

My two went like this (details changed to protect HIPAA). Additionally this is JUST the narrative, I also included medical history, medications, age, non-hipaa violating demographics, etc that we got on scene in another section of the document. I very rarely repeat their history in the narrative unless it is SPECIFIC to the run as I've already written that info on another page of the run form.

Cardiac Arrest 1:
Pt found supine, CPR in progress via FD. FD on scene states a neighbor heard a loud bang from suspected fall of the pt and initiated 911 response. Suspected downtime approx 25-30 minutes. Unk history, Unk Meds, Unk Allergies, ID on scene recovered by PD. FD reports AED attached no shock advised, CPR in progress for 10 minutes c minimal interruption. Defib pads attached to monitor, CPR halted. Pulseless, asystole. CPR resumed, intubation attempted c success by paramedic (7.0), IO access obtained, Epi 1:10000 1mg via IO, pt immobilized c minimal interruption. Rhythm and pulse reassessed. ROSC, pulse verified x2 carotid, sinus tach on EKG. Moved to ambulance -> C-3 <Hospital>. Enroute: ventilation's & O2 maintained, ETCO2 @ 46, EKG shows possible ST elevation in leads II, III, & AVF, 12-lead not obtained due to transport time and available resources. EKG trend to sinus brady, pulseless after reassessment. PEA (Sinus Brady). CPR resumed, Epi 1:10000 1mg, Atropine 1mg. Rhythm reassessed, pulseless, PEA sinus tach, CPR resumed, 3rd Epi given. Arrived to <hospital>, prior to transfer from stretcher to bed reassessed c ROSC. Pt moved, report given, care transferred to ER staff.


Cardiac Arrest 2:
Pt found supine in floor, CPR in progress by FD. Pt was found by husband approx 10 minutes prior to arrival unresponsive, not breathing. Husband pulled pt into floor and began CPR until arrival of FD. FD ventilating PT, AED attached, no shock advised. CPR ceased, EKG reads sinus brady PEA. CPR resumed. IO initiated R tibia, 1L Saline WO, Epi 1:10000 1mg & Atropine 1mg given on scene prior to transport. -> c-3 <hospital>. Enroute: Intubated 6.5 ETT, + ETCO2, +Breath Sounds x4, - Epigastric sounds, + Visualization. Ventilated 12/min BVM. Persists sinus brady PEA, epi 1:10000 1mg & Atropine 1mg given. Approx 5 minutes from hospital rhythm check reveals PEA @ 80, epi 1:10000 1mg given. On arrival to hospital pulses faint carotid, heart sounds extremely faint. Report given to <hospital> MD, care transferred to ER staff.

Linuss
04-18-2010, 09:56 PM
Totally depends on your protocols / schools wants, but:

Where was the IO started?
EDIT: I see you have it in your second report but not the first.



And did you reassess ET placement after each movement?

Dominion
04-18-2010, 09:58 PM
Totally depends on your protocols / schools wants, but:

Where was the IO started?

The second narrative states R tibia, the first narrative does not. These are direct copy pastes with just identifying info removed/changed so I did miss that. My school wants nothing less than absolutely perfect, I have yet to get my QA back on these two reports as we're a bit behind on that front. I know that they will be dissected I was just looking for other opinions on format, should I focus less on play by play and more on generalization. The first arrest was more of a up and down type scenario with several rhythm changes, pulses coming and going, etc while the second was more straight forward. We got there, she was PEA, she stayed PEA (although rate came up) until arrival when she regained faint pulses.

Edit War!: Tube was reassessed, but I didn't write it so it didn't happen. Another thing I missed.

piranah
04-18-2010, 10:14 PM
you do not have to write that you checked LS after every movement it is implied that correct practice was performed....you do however put LS in when describing the secondary/third assesment....

Dominion
04-18-2010, 10:29 PM
you do not have to write that you checked LS after every movement it is implied that correct practice was performed....you do however put LS in when describing the secondary/third assesment....

When you say secondary/third assessment what are you specifically referring to? Do you mean when you are performing additional assessments such as rhythm checks, pulse checks, etc?

Additionally would some of you be willing to type up an example cardiac arrest narrative? Maybe one from memory or just make it up? I'd like to see the other styles of what's out there.

MrBrown
04-18-2010, 10:56 PM
You guys seem to write overly complex and wordy entries, or is it just me? :P

PMHx: Triple bypass ~ 3 yr ago

Hx: Found collapsed on floor by coworkers

O/A: On floor, appeared poorly perfused and responsive to verbal stimuli of crew presence

O/E: Slow, shallow breaths ~ 8/min with fast, weak pulse. Appeared pale, sweaty and agitated. Denies chest pain and no previous history of this ocurring before. ECG > VT at 190.

Rhythm became nonperfusing, patient went unconscious with absent pulse.

Shock x 1 at 360J converted to sinus rhythm and patient regained consciousness.

Enroute: Nil significant change

Vital signs:
PR 190 BP 90/50 RR 8 GCS 13 (3/4/6) BGL 5.8
PR 100 BP 130/80 RR 10 GCS 14 (4/4/6) SPO 99% O2

Treatment:
Oxygen 10L NRB
IV attempt 16g R forearm
IV 16g L AC, 1L NS W/O
Shock x 1 360J (VT>SR)

Linuss
04-18-2010, 10:58 PM
You guys seem to write overly complex and wordy entries, or is it just me? :P

PMHx: Triple bypass ~ 3 yr ago

Hx: Found collapsed on floor by coworkers

O/A: Unresponsive on floor

O/E: Slow, shallow breaths ~ 8/min with fast, weak pulse. Appeared pale, sweaty and agitated. Denies chest pain and no previous history of this ocurring before. ECG > VT at 190.

Rhythm became nonperfusing, patient went unconscious with absent pulse.

Shock x 1 at 360J converted to sinus rhythm and patient regained consciousness.

Enroute: Nil significant change

Vital signs:
PR 190 BP 90/50 RR 8 GCS 13 (3/4/6) BGL 5.8
PR 100 BP 130/80 RR 10 GCS 14 (4/4/6) SPO 99% O2

Treatment:
Oxygen 10L NRB
IV attempt 16g R forearm
IV 16g L AC, 1L NS W/O
Shock x 1 360J (VT>SR)

That's not a cardiac arrest narrative...

And you're not in an as litigious country as we are.

Dominion
04-18-2010, 11:16 PM
That's not a cardiac arrest narrative...

And you're not in an as litigious country as we are.

I'm going to second this one. Here simple mistakes such as extra penstrokes in the margins on your paperwork can be twisted by a lawyer to make you seem careless. Our QA guy is a defense attorney that specializes in medical cases and has represented many EMS cases. This is something that HAS been pointed out to us by him. Making weird marks or maybe a stray mark has been used against him in a case to show the 'carelessness' of the person at trial. Not to say this is a common occurrence, but just the lengths some lawyers will go to in this country to attempt to win their case.

Melclin
04-19-2010, 01:58 AM
Don't you have templates to write these things against? Similar PCRs or something? Doesn't someone tell you how to write them?

Whats the purpose of it anyway? If its for school why are they getting you to recite a cardiac arrest algorithm? Wouldn't a reflective piece be a better? Or are you practicing for some requirement of the job. Do you guys write narratives like this after an arrest on the job? Whats wrong with the PCR?

Linuss
04-19-2010, 02:20 AM
Don't you have templates to write these things against? Similar PCRs or something? Doesn't someone tell you how to write them?

Whats the purpose of it anyway? If its for school why are they getting you to recite a cardiac arrest algorithm? Wouldn't a reflective piece be a better? Or are you practicing for some requirement of the job. Do you guys write narratives like this after an arrest on the job? Whats wrong with the PCR?

Most PCRs I've seen have a narrative section for a written out 'story' of what happened.

Melclin
04-19-2010, 03:07 AM
True, I suppose it depends what the PCR is like. I would have thought you would be listing your interventions more systematically for official paper work.

For our ePCRs you create a time line of interventions that are selected from menus. These should match up with the time line of obs.
eg:

14:34 - attempt IV access, 18g cannula/3 way extend. (successful)
14:35 - Medication administration, Adrenaline. 1 mg.
14:35 - Medication administration, 9% saline. 10ml (flush).
14:37 - DCCS (200J) (Vf -> SR)
....etc

which then match up with a table of observations:
__________14:34______14:39
BP ___unrecordable___65/palp
GCS__3 (e1v1m1) ____7(e1v2m4)

There is a narrative spot as well, but I don't know that you'd include every detail considering its listed in vitals/interventions. Do you guys typically have different sections for that? Is it typical to list interventions so informally?

It just seems like, especially with the legal eagles in mind, that there is more room for confusion with a single block of text full of abbreviations and shorthand, than with clearly labeled separate sections, each with a clear chronological order. I'm sure you have the way that you are supposed to do things OP, I'm not arguing here, just wondering.

Veneficus
04-19-2010, 04:30 AM
the best arrest chart I ever saw was written by a friend of mine who has an uncanny ability to say complex things in a very few words without being overly simplistic.

"Found patient pulseless/apnic, followed ACLS algorythm for PEA/Asystole to termination of efforts."


What more could possibly be said about that?

usafmedic45
04-19-2010, 04:44 AM
you do not have to write that you checked LS after every movement it is implied that correct practice was performed....

...right up until you get called into court. ;)

Just a helpful reminder from your friendly neighborhood airway expert for hire.

Dominion
04-19-2010, 07:14 AM
Ok. Let me start over since it seems there is some confusion, specifically from the non-US crowd. Our PCR's locally look like the following:

Front page:
The front page contains things like demographics, response times, mileage for your ambulance, misc stuff like other responders, reasons for delay in care (IE Extrication, road hazards, etc), medical history, medications list, allergies, cardiac arrest info (time of arrest, witnessed or non-witnessed, cpr initiated time, etc), and some misc billing info.

Back Page:
The first 1/3 of the page is the "Initial Head to Toe", this lists each head to toe assessment category (LS, Airway status, etc). The next 1/3 is vitals, medications given (including times, route, dosage, etc), EKG results, and IV status. This is filled out for EVERY medication given and for each instance as well as what time it was done. The last 1/3 is the narrative, wherein MOST people repeat everything that has already been said.

So we do have what you're talking about, however for class I have a somewhat different approach. We don't focus as much on the times things were given as it's not entirely a legal document that will go to court, it focuses us more on our narrative writing, our patient interviews, and various skills we are required to perform in our ride alongs.

My preferred narrative focuses on a start to finish method of what happened (story mode), I do not include history, meds or allergies unless that patient has something VERY specific to the incident. Such as an MI and they have a history of MI, CAD, HTN, Smoking and has taken NTG and ASA, that goes in my narrative. When I write my narrative I do something like <what I found>, <What they say happened (or bystander says), <what I did on scene>, <what I did enroute>, <what changed>. So for example I may write "Onscene performed inital VS, 12-lead EKG reads sinus rhythm, O2 4lpm NC. -> C-3 <hospital name>. Enroute: VS monitored, O2 maintained, physical exam performed as recorded above........" Then if anything changes from that initial exam, it goes in the narrative.

DEmedic
04-19-2010, 02:15 PM
A general thought; I don't know if you're writing paper reports or writing an ePCR narrative, but I find if I jot down some notes first, it makes my narrative easier much to write. It keeps things in correct order in the SOAP format (which both of the services I work for are sticklers about) and it keeps me from forgetting to put the important "legal/CYA" stuff in the narrative. rather than "patient moved to MICU", I remember to always write, "patient moved to stretcher via 2 person draw sheet lift, secured with safety straps. Stretcher moved to MICU and secured." My narratives are rather detailed, but my MPD has told me several times that I paint a vivid picture of the patient's condition ... and he's used my reports as teaching models for other medics who have less than stellar repoert writing skills.

The report that looks like this, "PT found on couch C/O SOB -> Albuterol TX/VS/HX/PE -> Move to MICU -> IV LAC -> Arrive ED - XFER care" simply won't fly around here.

Here's a sample Chest Pain/Brady SOAP that i had on my computer...

Medic 21 was dispatched priority to a private residence for a 56 year old male C/O low blood pressure and feeling dizzy with a slight SOB. PT states he had been feeling unwell, with some chest pain and fatigue since yesterday afternoon following power washing his deck. The pain yesterday was described as a sub-sternal burning pain rated as“13 out of 10”. Believing this pain to be heartburn, the PT took OTC antacid and received no relief. This evening he was still feeling dizzy with some CP, and took his BP with a home machine. His BP was 84/52, so he summoned 911. The PT has a history of hypertension and takes Metoprolol 50mg, Amlodipine 5mg, Clonidine 25mg and HCTZ. There have been no recent medication changes and he has been compliant with his meds and is positive he has not taken any more than usual. The patient is also a smoker and has recently reduced his consumption to a half pack a day. PT denies any diaphoresis or nausea or vomiting. PT has no other complaints aside from the chest tightness and slight SOB. PT’s last meal was a turkey sandwich about 90 minutes prior to our arrival.

Upon our arrival, PT was found sitting on the edge of his bed. He had just extinguished a cigarette as we arrived. He was CAOx3, GC15. His skin was cool and dry and pulse was slow and weak. BP: 86/62 HR: 52 RESPIR: 16 SpO2: 96% on RA. The monitor showed Sinus Brady with a rate of 50 with no ectopy. 12 lead was unremarkable with no noted ST elevation. HEENT: No trauma noted, Pupils PERRL. CHEST: Lung sounds were clear and equal bilaterally. PT says his chest “feels tight at about a 4/10.” No radiation. No palliation. Has felt that way all day. ABD: Soft and non-tender in 4 quadrants. PELVIS: Intact. EXTREMITIES: No edema noted. His extremities were cold to the touch, with slow capillary refill.

PT to be transported to XXX Hospital ALS to R/O MI.

BSI, PT contact followed by interview questions. PT placed on 2 LPM of O2 via NC. SpO2 to 99% with Oxygen. Vitals obtained. PT placed on monitor and 12 lead obtained. The patient was able to stand and ambulate without difficulty. He was assisted in walking approximately 10 feet from his bedroom to the front door where he sat on the stretcher and was placed in a semi-fowler’s position, covered with blankets, secured with straps and moved to MICU. PT was assisted into a hospital gown. IV access was established in the Right AC with an 18ga angiocath and a 500ml fluid bolus of NS was started. PT was administered 324mg of ASA and 0.5mg of Atropine IVP. Following the fluid bolus and Atropine, vital signs were reassessed. BP: 102/88, HR: 72, RESPIR: 16 Lungs remained clear bilaterally. IV drip rate adjusted to TKO. PT was administered 0.4mg Nitro SL. Telephone report to ED was made. A second 12 lead showed NSR at a rate of 72 with no ectopy or ST elevation noted. On arrival at ED, PT was transferred to bed 8 via 3-man draw sheet lift and report given to Melodie, RN. PT care and transport occurred without complication or incident. Signatures obtained and Medic 21 returned to service.

Dominion
04-19-2010, 03:57 PM
A general thought; I don't know if you're writing paper reports or writing an ePCR narrative..........

These are ePCR but are not full on ePCR software, they are more geared for class than a full on PCR. I tend to write the same narrative as you listed at my full time position with the only difference being I don't list my physical exam findings, I don't list medications, I don't list hx, and I don't give every detail of moving a pt etc. This is similar to a narrative I write at work.


"Pt found supine, c/o abdominal pain. Pt states that pain started approx 10pm last night and that they have never felt anything like it before. Pain is @ 10/10, LRQ, does not radiate, worse on palpation, sharp in nature. Pt states she took some antacid last night approx 11pm s relief. Initial VS obtained, O2 applied 4lpm NC, pt ambulatory to stretcher s incident. -> <C-1 or C-3> <hospital name>. Enroute: VS monitored, O2 maintained, Physical exam as noted above. Pt now + N/V approx 50cc clear fluid. Arrived to <hospital name> - changes in initial exam. Triaged to <room number> and care turned over to nursing staff in ER. "

DEmedic
04-20-2010, 03:36 AM
It's funny, but the stuff that comes back to bite you on the @ss is the simple stuff. Forgetting to document that you put the rails up on the bed after you transfered the patient. Forgetting to note that you secured the safety straps on the stretcher. Little stuff, like the name of the nurse you transfered care to. Poor spelling. Poor grammar. That stuff really comes back to get you and can make you look like an IDIOT. If all of your PCRs have the same standard format and you make note of the same CYA stuff, your narrative becomes much more defendable when you get called into a deposition or have to appear in court. "Yes sir, I always secure all of the staps on the backboard and make note of it on each PCR that I write..."

You've got to remember that each PCR is a threefold document. It not only must to paint a pre hospital picture of the patient and surroundings, it also has to prove that your provided competent, correct care and it's got to be accurate and correct for billing.

And even though your class document isn't a real "legal document", you should treat it as one. Get in the habit of writing a FULL and complete narrative. Trust me. Go to court once and all of your PCRs will immediately become more legible and MUCH more complete. You'll never look at a report the same way again :)

tazman7
05-20-2010, 07:46 PM
There are so many options on the Lifequest program that I dont even know why we have to write a narrative.. most of my naratives for codes are something like:

D86 called code three for cardiac arrest. UOA pt found laying supine on floor, still warm but pale and cyanosis. Family witnessed arrest. Pt has no medical history, nkda, no meds.

cpr initiated
pt was bagged at 8 per min
cardiac monitor applied- showed asystole
iv was initiated in left ac with 18ga running ns tko
pt intubated with 7.5 tube- confirmed by breath sounds- chest rise- visualization of cords- mark is at 22 on teeth- tube secured with tape
1mg epi given
cpr
1mg atropine
cpr
pt transferred to cot and into ambulance-cpr still in progress.
1mg epi
cpr

and so on....


Now if there is a call that needs documentation then obviously I will write more. But our program basically asks everything that you would write in your report anyways such as meds given- time meds were given- medical history- allergieds- meds- I feel that if I have to take the time to click every one of the 1000 options the program makes you do then the doctor or lawyer can take the time to read through the report to find the information, because its there.

alphatrauma
05-20-2010, 11:57 PM
The system I currently work in uses the

ACHARTE format:

Arrival
Chief complaint
Assessment
R - Treatment
Transport
Exceptions

My first full arrest narrative was pretty straight forward using the ePCR and ACHARTE. The Zoll code markers helped a lot with times

alphatrauma
05-21-2010, 12:52 PM
The system I currently work in uses the

ACHARTE format:

Arrival
Chief complaint
History
Assessment
R - Treatment
Transport
Exceptions

My first full arrest narrative was pretty straight forward using the ePCR and ACHARTE. The Zoll code markers helped a lot with times

fixed

Dominion
05-21-2010, 10:03 PM
I tend to use ACHARTE in my narrative style except I tend to do it in this order:

Arrival
Chief Complaint
History of complaint
Assessment
Transport
R - Treatment
Exceptions

Sooo ACHATRE...sounds like it could be french ;)

1badassEMT-I
06-21-2010, 10:29 AM
It's funny, but the stuff that comes back to bite you on the @ss is the simple stuff. Forgetting to document that you put the rails up on the bed after you transfered the patient. Forgetting to note that you secured the safety straps on the stretcher. Little stuff, like the name of the nurse you transfered care to. Poor spelling. Poor grammar. That stuff really comes back to get you and can make you look like an IDIOT. If all of your PCRs have the same standard format and you make note of the same CYA stuff, your narrative becomes much more defendable when you get called into a deposition or have to appear in court. "Yes sir, I always secure all of the staps on the backboard and make note of it on each PCR that I write..."

You've got to remember that each PCR is a threefold document. It not only must to paint a pre hospital picture of the patient and surroundings, it also has to prove that your provided competent, correct care and it's got to be accurate and correct for billing.

And even though your class document isn't a real "legal document", you should treat it as one. Get in the habit of writing a FULL and complete narrative. Trust me. Go to court once and all of your PCRs will immediately become more legible and MUCH more complete. You'll never look at a report the same way again :)

You speak the truth.....go to court ONE time and let the DAor Defense attorney rip that PCR to hell and back you will think twice about how you write the PCR.....