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Old 01-24-2010, 10:51 PM   #1
AnthonyM83
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Post Examples of PCR Narratives


I know different philosophies and formats for patient care report narratives, but looking to see various examples of them. How those formats and philosophies actually play out into actual narratives. Also, notes on whether there are separate sections for information left out (GCS, Vitals, Hx, etc).

Also, looking to read real ones that are actually used (versus "perfect" ones that would be rated an A+). Just seeing how many pertinent positives, negatives people might use (what's a good amount versus overkill).

Just throw out some examples for common things like : Chest Pain, Shortness of Breath, Seizure, Abdominal Pain, Minor Injuries, Major Traumas, Cardiac Arrest, "Sick" calls...whatever you like


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Old 01-25-2010, 12:39 AM   #2
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I work for/with a department that requests it's crew chiefs write very standardized PCRs. The calls the department encounters tend to be minor medicals, etc, and often refusals, but can range widely, yet we still use the same algorithm. A minor trauma (refusal) would look something like this

(SC) OAF 24 yom, CA+Ox4, seated on stairs, ICO friends. (CC) Ankle Pain (HPI) Pt. states he was walking down stairs when he fell down "3" steps, and "twisted" ankle, 5 min PTOA, then walked to scene (approx 50'). Pt denies falling, hitting head, prior weakness, states prior "twisting" ~5 years ago. -LOC, -H/N/B pain, -DZI, -CP, -DB, -SOB, -ABD Pain, -N/V/D, +CSMx4, -DCAPBTS, +L. Pt. denies all other pain or abnormality. (PE) Vitals as noted. Pt c/o 4/10 "sharp" pain to L lateral ankle, increasing upon palp, pressure, decreasing with cold compress. pt able to ambulance w/o assistance, but with pain. + distal CSMs, + ROM. Skin P/W/D, Pupils PEARL, LS clr=bilat. Rest of Secondary survey unremarkable. (TX) VS assessed, PE performed, ice pack applied, with some relief. Pt. advised of treatment and transport options. Pt expressed intent to refuse care at this time, call clinic, receive transportation from friends, and receive care "ASAP". (TP) Pt. refusal signed and witnessed (by XX). Pt left ICO friends, with instructions to follow up at clinic ASAP and call if further care needed.
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Old 01-25-2010, 01:10 AM   #3
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Is it sad that I can understand and read that entire narrative without a moments pause?


I typically do a mixture of SOAP and CHART... trust me, it makes more sense when it's written out. Sadly I don't have one near by, and seeing as it's after midnight, my imagination is non-existent. Just know that it's awesome.
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Old 01-25-2010, 01:14 AM   #4
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Given a blank page, I tend to use a variation of SOAP, called: SOAPIE or SOAPIER... depending upon if I have to revise the plan...

If the report isn't completely blank, I modify my charting style to prevent writing stuff down twice. When I do this, I make certain that everything I do has a time associated with it so that a timeline of events could be recreated without much, if any, effort.

Last edited by Akulahawk; 01-25-2010 at 01:20 AM.
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Old 01-25-2010, 03:28 PM   #5
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Originally Posted by Linuss View Post
Is it sad that I can understand and read that entire narrative without a moments pause?


I typically do a mixture of SOAP and CHART... trust me, it makes more sense when it's written out. Sadly I don't have one near by, and seeing as it's after midnight, my imagination is non-existent. Just know that it's awesome.
Not sad unless it is sad that I can too........

I usually use a mix of SOAP(E) and a sequential narrative. It turns out more like SOPEA I don't like using abbreviations much, so mine can turn more like a story than a report.

eg:

S/O: Unit dispatched to 123 N. Random St. for a 68 yom sick u/k, hx DM. OAF pt sitting in easy chair, decreased response. RP states pt "was here when I went to bed and was in the same spot when I woke up". Pt has hx DM and is not insulin dependant, hx of low BGL. RP states LOI probably 1800 on (date).

I/A: A: Patent. B: Shallow non-labored. C: Weak Radial. Good cap-refil. C-spine: No MOI. Pupils: PEARL. LOC: Pt responds to loud verbal. Bleeding: None. Skin: Cool, pale, moist. HEENT: 0 abnormalities noted. Chest: Equal + bi lat expansion w/ resp. Lungs: Clear equal and bi-lat upper and lower, front. Heart: ST. Abd/pelvis: 0 abnormalities noted. Back: Not examined. Ext: good movement X4. Edema in lower ext. Neuro: Pt confused and combative. Hx: DM. RP states no other PPMHx. RP states NKA/NKDA. Meds: See attached.

P: I/A, vitals (see below), 3 lead, BGL (34), IV 16 ga L AC, 25 ml D50% SIVP, + 5 min BGL (50), 25 ml D50% SIVP, +5 min BGL (95), O/A.

O/A: Pt's LOC improved to Alert. Pt became A&Ox4, states LOI approx 1830 on (date) got distracted watching TV and forgot to check BGL later in PM. Pt denies any other problems. Pt refused transport. Advised to eat something as soon as possible. Pt signed refusal, withnessed by xxx and xxx. Pt left ICO wife.

~~~~~~~~~~~

Ok, so that is a made up scenario, so I'm sure I left some things out.
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Old 01-25-2010, 03:42 PM   #6
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I think this is the best format

http://www.youtube.com/watch?v=FrS9JS-FtcQ

sorry, couldn't resist.
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Old 01-25-2010, 08:58 PM   #7
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I like to use a form of the CHART method called LCHARTI:

(L)ocation
(C)hief complaint
(H)istory of Present Illness/Injury
(A)ssessment
(R)x - prescription/treatment
(T)ransport
(I)mpression

(Location): Medic 1 responded to above location on a report of a 62 y.o. male c/o of chest pain. Upon arrival, pt presented sitting in a chair attended by first responder. Pt appeared pale and having difficulty breathing.

(C/C): "I have pain in my chest"

(HxPI): Pt had a sudden onset of substernal chest pain ~1 hour prior. PMHx of AMI 2 years prior with cardiac catherization with stints placed, COPD, 20+ year smoker, hypercholestermia.

(Assessment): Pt AOX4, GCS=15. Skin pale, cool, & diaphoretic. No JVD noted. Pt c/o chest pain/pressure 8/10. Lung sound clear += in all fields. Remainder of exam was unremarkable. No peripheral edema noted. Pt also c/o nausea. Last oral intake was breakfast at 08:00 this am.

(Rx): vitals, oxygen, monitor, 324 mg ASA PO, I.V. established 18 g (R) AC @TKO rate, 12-Lead aquired showing showing ST elevation in Leads II & III. NTG sublingual with decrease of pain to 4/10, transport.

(Transport): Pt transferred to stairchair and transported down stairs. Pt transferred to gurney and then ambulance. Report to medical control, no instructions recieved. Pt transported to hospital without incident. Pt condition improved.

(Impression): chest pain r/o AMI
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Old 01-25-2010, 09:54 PM   #8
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I think this is the best format

http://www.youtube.com/watch?v=FrS9JS-FtcQ

sorry, couldn't resist.
Yeah, but I'd sound better...
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Old 01-26-2010, 12:14 AM   #9
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Here ya go... Standard SOAP.

Medic 19 dispatched priority @ 1854 to a private residence for an 85 year old male experiencing SOB and CP. PT states he was attempting to drain the water from his basement following his sump pump malfunctioning. As he became more anxious, he began having increased difficulty breathing and SOB, accompanied with sub sternal CP. PT states he took one 0.4mg NTG SL 10 minutes prior to our arrival with full relief. PT has a history of NIDDM, a MI over 10 years ago, a Coronary Bypass 6 years ago, HTN, GERD and anxiety. Pts medications include Simvastatin, Glipizide, Losartan, Zantac and NTG. PT has a sensitivity to Morphine Sulfate and is allergic to shellfish. PT has been complaint with his medication, according to his wife. PTs last meal was a chicken breast and rice.

Upon our arrival PT was found sitting on the couch, in a high state of anxiety due to his flooded basement. PT was CAOx3, GCS 15, with no signs of trauma noted. He was breathing rapidly and complaining of SOB and tingling around his lips and his fingers. He stated he had some “chest tightness earlier, but it was gone now” following his NTG administration. PT skin was pink,warm and dry. BASELINE VITALS: HR 92, BP: 150/80, RESPIR 26, SpO2 98% on RA. TEMP: 98.4. BGL: 112 12 LEAD: NSR at a rate of 88, with no ST elevation noted. HEENT: Pupils PERRL, no signs of trauma noted. No TD or JVD noted. CHEST: Lung sounds: Clear and equal bilaterally. ABD: Soft and non tender. PELVIS: Intact. EXTREM: PT had good PMS in all extremities.

Pt transported to Hospital ED R/O anxiety/hyperventilation.

BSI, PT contact and interview. Vitals as above. PT placed on monitor and 12 lead obtained within 10 minutes of our arrival. (Attached). PT placed on 3 lpm of O2 via NC with ETCO2. PT was able to stand and pivot to stretcher and was secured with safety straps. Pt was moved to ambulance for detailed exam which was unremarkable. IV access was obtained in L AC 18G with 1000ml of NS set at TKO rate. During transport, PT was coached on slowing his breathing and would slow for a short time and then immediately return to his previous tachynpea. En route VITALS: HR: 88, BP: 132/70, RESPIR: 24 and non labored. SpO2: 100 on 3 lpm via NC. ETCO2: 27. Lungs remained clear and equal bilaterally. PT tolerated transport well and stated that he continued to be pain free. Telephone report to ED was made to notify staff of impending arrival. Upon arrival at ED, PT was moved to room 2 via 3 person draw sheet lift. Report given to John Doe, RN. Prior to leaving the ED, I notified the PT that the crew from Engine 18 had repaired his sump pump and his basement was being pumped out. He seemed to relax somewhat after hearing that news. Transport occurred without incident or complication and Medic 19 returned to service at 1957.
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Old 01-26-2010, 12:20 AM   #10
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Here ya go... Standard SOAP.

Medic 19 dispatched priority @ 1854 to a private residence for an 85 year old male experiencing SOB and CP. PT states he was attempting to drain the water from his basement following his sump pump malfunctioning. As he became more anxious, he began having increased difficulty breathing and SOB, accompanied with sub sternal CP. PT states he took one 0.4mg NTG SL 10 minutes prior to our arrival with full relief. PT has a history of NIDDM, a MI over 10 years ago, a Coronary Bypass 6 years ago, HTN, GERD and anxiety. Pts medications include Simvastatin, Glipizide, Losartan, Zantac and NTG. PT has a sensitivity to Morphine Sulfate and is allergic to shellfish. PT has been complaint with his medication, according to his wife. PTs last meal was a chicken breast and rice.

Upon our arrival PT was found sitting on the couch, in a high state of anxiety due to his flooded basement. PT was CAOx3, GCS 15, with no signs of trauma noted. He was breathing rapidly and complaining of SOB and tingling around his lips and his fingers. He stated he had some “chest tightness earlier, but it was gone now” following his NTG administration. PT skin was pink,warm and dry. BASELINE VITALS: HR 92, BP: 150/80, RESPIR 26, SpO2 98% on RA. TEMP: 98.4. BGL: 112 12 LEAD: NSR at a rate of 88, with no ST elevation noted. HEENT: Pupils PERRL, no signs of trauma noted. No TD or JVD noted. CHEST: Lung sounds: Clear and equal bilaterally. ABD: Soft and non tender. PELVIS: Intact. EXTREM: PT had good PMS in all extremities.

Pt transported to Hospital ED R/O anxiety/hyperventilation.

BSI, PT contact and interview. Vitals as above. PT placed on monitor and 12 lead obtained within 10 minutes of our arrival. (Attached). PT placed on 3 lpm of O2 via NC with ETCO2. PT was able to stand and pivot to stretcher and was secured with safety straps. Pt was moved to ambulance for detailed exam which was unremarkable. IV access was obtained in L AC 18G with 1000ml of NS set at TKO rate. During transport, PT was coached on slowing his breathing and would slow for a short time and then immediately return to his previous tachynpea. En route VITALS: HR: 88, BP: 132/70, RESPIR: 24 and non labored. SpO2: 100 on 3 lpm via NC. ETCO2: 27. Lungs remained clear and equal bilaterally. PT tolerated transport well and stated that he continued to be pain free. Telephone report to ED was made to notify staff of impending arrival. Upon arrival at ED, PT was moved to room 2 via 3 person draw sheet lift. Report given to John Doe, RN. Prior to leaving the ED, I notified the PT that the crew from Engine 18 had repaired his sump pump and his basement was being pumped out. He seemed to relax somewhat after hearing that news. Transport occurred without incident or complication and Medic 19 returned to service at 1957.
That is a fine report, I need to get better at the one's I do for clinicals.
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