EMT student and I need help

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Amber

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I did my second hospital ER shift and we had a 7 day old baby come in, we are to do a narrative in CHARTE format, but I'm unsure how to do this on a neonate. Our instructor gave us an example for the adults, but said its different for babies, yet didn't give us an example.
I have all the info on the baby, and the mothers pregnancy, I'm just unsure how to word everything, and where to put everything
Does anyone have or know where i could find an example of a CHARTE on neonates?
Thanks in advance.
 
Writing narratives, especially for patients that we don't see often should not be based off of a straight rubric, but the information you have at hand. Try opening a word processor on your computer and making the headings for CHARTE, and filling in the information you already know.
Have you already done the peds lecture in class? If so, you can discuss specific elements of your physical exam based on age(interactivity, etc). No two narratives are going to look the same-- but just tell them what you know.
 
emt.dan said:
Writing narratives, especially for patients that we don't see often should not be based off of a straight rubric, but the information you have at hand. Try opening a word processor on your computer and making the headings for CHARTE, and filling in the information you already know.
Have you already done the peds lecture in class? If so, you can discuss specific elements of your physical exam based on age(interactivity, etc). No two narratives are going to look the same-- but just tell them what you know.
Click to expand...

No we haven't, and I think that's where I'm having some confusion. I have read the chapters on my own, but it doesn't talk about documentation for them.

I know there is specific things that need to be said a certain way though.

My preceptor gave me the go ahead to do my assessment on this baby, because as he said "we dont get that many tiny ones like that, go ahead" Im sure its just because the baby was stable, and it was a frighted mother.
 
Are you required to use CHARTE?
 
More than likely no one else will know how either so just do the best you can and ask your instructor next time you see him.
 
bigbaldguy said:
More than likely no one else will know how either so just do the best you can and ask your instructor next time you see him.
Click to expand...

Nobody else seen any kids, and its due tomarrow, and the clinical was just yesterday. I hate when they do things like this. I dont have a chance to ask questions.
 
Im going to be totally upfront about this. I dont use (and didnt learn CHARTE) but it could be


chief complaint + history - based on what the caregiver told you
assessment - your assessment
treatments - your treatments
transport - transport
exceptions - I dont know CHARTE so not sure what this means
 
94H said:
Im going to be totally upfront about this. I dont use (and didnt learn CHARTE) but it could be


chief complaint + history - based on what the caregiver told you
assessment - your assessment
treatments - your treatments
transport - transport
exceptions - I dont know CHARTE so not sure what this means
Click to expand...

ok so how would you do a narrative for a 7day old? I am just not understanding what info is spose to be in there and what is just "extra" stuff.
Also please keep in mind this was a clinical at an ER not on the ambulance.
 
Why was the 7 day old in the ER?

How long have they had this problem?
Anything make it better or worse?
What did EMS do for the baby? (If they were transported in by EMS)
 
94H said:
Why was the 7 day old in the ER?

How long have they had this problem?
Anything make it better or worse?
What did EMS do for the baby? (If they were transported in by EMS)
Click to expand...

The baby had breathing problems during a crying spell. And mom was worried about bubbles in the babys mouth

When the baby stopped crying the breathing probs stopped. Nothing mom noticed made the bubbling any different.

The baby was brought in my mom.

xrays where done, normal, and baby had GERD.
 
what is CHARTE?<br />
<br />
SImilar to SOAPE?
Click to expand...
<br />
<br />
yea kinda,<br />
chief complaint<br />
history<br />
assessment<br />
treatments<br />
transport<br />
exceptions
Click to expand...

So 7 day y.o infant brought into wherever by whoever for whatever reason.

History about the pregnancy and birth. Full term blah blah blah.

Baby crying, fussy, calm. What lungs sounded like and vitals.

Whatever you did for the baby.

Where the baby ended up. Dischargrd or admitted.

And anything else you would like to add about what happened
 
Anjel1030 said:
So 7 day y.o infant brought into wherever by whoever for whatever reason.

History about the pregnancy and birth. Full term blah blah blah.

Baby crying, fussy, calm. What lungs sounded like and vitals.

Whatever you did for the baby.

Where the baby ended up. Dischargrd or admitted.

And anything else you would like to add about what happened
Click to expand...

ok so where would the PMS go? we have to check typical newborn reflexes and such, i dont know what to call them, we do a head to toe assessment on every patient.
 
Amber said:
ok so where would the PMS go? we have to check typical newborn reflexes and such, i dont know what to call them, we do a head to toe assessment on every patient.
Click to expand...
Assessment for CHART, objective for SOAP.
 
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