Full Arrest Narrative

[Melclin]

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]

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]

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]

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]

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]

Originally Posted by n7lxi

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]

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]

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]

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]

Originally Posted by alphatrauma

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