Improving Documentation

LucidResq

Forum Deputy Chief
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I'm an EMT student, and I want to focus on documentation.

I found a pretty effective way to practice writing reports... by taking a copy of a report written by someone else, translating all of the abbreviations and stuff into a paragraph form, and then rewriting it in my own style without looking at the original. My teacher has offered to look over my practice reports and critique them.

Any other tips on effective documentation? Anyone know of good web resources?

I'm also seeking a website with comprehensive case reports that I can write my own reports off of.
 

enjoynz

Lady Enjoynz
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We use the mnemonic:CHOTIP

C - Chief complaint - e.g. Chest pain
H - History - How it happened
O - On examanation - What we found
T - Treatment - What we did
I - In transit - How did they travelled on route.
P - Past medical history - Relevant past events.

Plus - Vital signs, Medications, Allergeries,and Meds given.

That covers most things on our Patient Report Forms.
Of course it maybe total different for you in the States.

Cheers Enjoynz
 

Jolt

Forum Crew Member
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I was taught "CHART":

Chief Complaint
History
Assessment
Received _______ treatment
Transfer of care
 

ffemt8978

Forum Vice-Principal
Community Leader
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Here we are mandated by the state to use the SOAP format:

Subjective
Objective
Assessment
Plan
 

SC Bird

Forum Lieutenant
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In school here, we are required to use the SOAP format. Takes some getting use to, and we are going to get critiqued and graded on all of our reports from here on out....

I don't mind the format, I just like a review with an instructor (while I am in school) of what I did do and didn't do so.

-Matt
 
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LucidResq

LucidResq

Forum Deputy Chief
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My school teaches CHART and SOAP, but it seems most of the instructors prefer SOAP so it's the style I've been practicing in, but I plan on attempting CHART also to see how I like it.
 

skyemt

Forum Captain
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while there are many tips for getting all the details down, as posted above, if you remember to document the following, you will eliminate a majority of documentations issues:

what did you find?

what did you do about it?

how did the patient respond?


hope it helps.
 

BossyCow

Forum Deputy Chief
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I have always recommended that new EMTs, ride alongs or students write their own report of every call they are on. Then we go over it comparing it with the report of the lead on the call. I make a bunch of copies of blank MIRs to use for this.
 

Topher38

Forum Lieutenant
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During my ride alongs, I wrote my own PCRs and the Paramedic riding with me would critique them as well. ^_^ mucho helpfuloo

I was taught CHART and SOAP
 
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