How do you do your reports?

[Flightorbust]

I was just wondering what form every one uses to do there report. Do you use S.O.A.P. narrative or another form when writing the report. Also does your agency require you to do it in a certain way or is it left up to you?

 

[JPINFV]

Back when I was working on an ambulance, I used a chronological narrative format. Now that I've had SOAP shoved down my throat, I've come to like a properly formatted SOAP note (most EMS SOAP notes aren't properly formatted in my opinion), and if I started working on an ambulance tomorrow, I'd use a modified SOAP format that I've come to call Pre-SOAPeD.

Link

Edit: ...and feedback on that modification is always welcome.

 

[epipusher]

I tapped a series of boxes and tabs on my computer. Now chronologically.

 

[NomadicMedic]

Delaware has a statewide electronic PCR system called EDIN. A report is a lot of fill in the blanks, pick boxes for pmhx, meds and allergies, a narrative style HPI, general impression and additional narrative. All procedures and vitals are documented in a timeline from PT contact to hospital arrival. Not a bad system, and I'm pretty used to it now. It's quick filling in vitals if you print a summary from the Lifepak.


Sent from my iPhone.

 

[Tigger]

I wish we had computers, maybe this winter...

I write my narratives based on the times associated with the call. The call is broken down into Dispatched, On-Scene, Transport, On-Arrival, Clear.

The type of call, chief complaint, and response priority are mentioned first in the "dispatch." O/S is not surprisingly, how the patient was found, what was done for the patient, and how the patient was transferred to the ambulance. Transporting includes further interventions in the ambulance and transport priority. O/A and Clear covers how the patient was transferred to the facility's bed, and the handover to the staff.

I try to specifically detail every patient move, and that all seatbelts and siderails were used for every call. Any equipment used goes in the narrative, as does a GCS or AOx scale. Generally I don't write vitals in the narrative, there is a separate space for them

 

[EMSrush]

Zoll ePCRs. I kinda miss paper.

 

[JPINFV]

Zoll ePCRs. I kinda miss paper.

I had a chance to look through some of the ePCR programs at EMS World Expo. I wanted to slap a few of them, especially the one that didn't include a way to easily add pertinent negatives "but hey, we're NEMSIS compliant."

To be honest, I wasn't really impressed with ePCR systems at all, especially since there was no way to format text in a manual entry box.

 

[Tigger]

I had a chance to look through some of the ePCR programs at EMS World Expo. I wanted to slap a few of them, especially the one that didn't include a way to easily add pertinent negatives "but hey, we're NEMSIS compliant."

To be honest, I wasn't really impressed with ePCR systems at all, especially since there was no way to format text in a manual entry box.

I forgot about the pertinent negatives, I try to include Chest Pain, SOB, Nausea Vomiting, and Dizziness in all of them.

 

[JPINFV]

I forgot about the pertinent negatives, I try to include Chest Pain, SOB, Nausea Vomiting, and Dizziness in all of them.

Hence why all patients need a review of systems completed. It's an assessment safety net that is, unfortunately, not taught (at least to EMTs).

 

[EMSrush]

I had a chance to look through some of the ePCR programs at EMS World Expo. I wanted to slap a few of them, especially the one that didn't include a way to easily add pertinent negatives "but hey, we're NEMSIS compliant."

To be honest, I wasn't really impressed with ePCR systems at all, especially since there was no way to format text in a manual entry box.

I've never considered slapping my computer, but have considered throwing it a few times. LOL

I add all pertinent negatives in my narrative manually. It's very easy to make a boo-boo when tapping different options when you're tired, so you need to be very careful. And my favorite: accidentally deleting a signature. I love it, I really do...

Paper PCRs have much less drama... and are more sanitary, too.

 

[epipusher]

Siren ePCR is a godsend.

 

[DrParasite]

EMScharts is used pretty much statewide for every ALS agency.

it has increased the time it takes to write a chart (esp for those people who don't write their charts as the call is progressing and end up 8 charts deep halfway through their shirt), but the ability to run reports based on the information, recall past patient information from the main database, no longer have to worry about provider's poor handwriting (guilty of that one), and an increase in the Qa/QI for completeness prior to chart submission makes it a worthwhile advantage in my book.

Plus the ER can access any patient's prehospital chart that we drop off simply by going to a website. now whether or not the staff nurses remember how to do that is a completely different story.

Basic charting for me for old paper charts, fill out every check box, then:
u/a found patient in xyz position cc or c/o chief complaint. how long it is going on for and what interventions he took prior to my arrival. pertinent negatives and anything else he tells me about the complain go here. than every intervention I do gets listed in the order it was applied or administered, transported to ambulance, M+T to hospital TOT RN with report given.

BTW, some are of the belief that if you didn't write it on the chart, than it didn't happen. I am not of that belief; I write the pertinent information, and don't document things like "secured with 3 straps on cot" or "patient with a stubbed toe was not complaining of chest pain." If I were to write every meaningless thing as a CYA, I would have to include "pt was not molested in the back of the truck," "ambulance did not crash enroute to hospital," "lighting did not strike patient as we he was being wheeled to ambulance," and my personal favorite "despite being well groomed, 9 month pregnant female was not told that she had a very nice looking vagina." you want to be thorough in all your important information, and yes, if something is relevant, be sure to write it down. and yes, pertinent negatives should be used on every medical call (just like every medical call should say no traumatic injuries noted on assessment). but don't go over kill because if you don't write it down it didn't happen.