Narrative

[joo]

One of my fellow new EMT's is having trouble writing her narratives. I find it a pretty simple task. Does anyone have a link, or a guide to helping her writing a narrative? Was looking for kind of a print out to give her.

She is a non-emergency transport emt, but would like to do 911.

 

[Epi-do]

There are several different formats that she could use to write her reports. I personally follow a chronological format. It is just the easiest for me to write. I have seen people that use the SOAP method as well. Here is a slide show that does a decent job of explaining the SOAP method.

I know there are other formats, but those are the only ones I can think of off the top of my head. Tell her to read as many reports written by other people as she can. It also helps to practice writing narratives. She could take a blank piece of paper and write a narrative for a run that she was on, but for some reason someone else wrote the report. The more she does it, the easier it will get for her.

 

[Tincanfireman]

Here's the way I write mine, keeping in mind that vitals, assessment, etc are recorded elsewhere in the computer...

"Dispatched to transport pt from SNF to local dialysis clinic for routine treatment. UOA, pt found supine in bed, CAO x 4 with no new pain and asymptomatic for trauma or illness. Pt moved to FW x 2 EMS via sheet drag from bed to cot. Pt secured x 3 straps and rails up x 2. Pt placed in semi-fowlers position with pillows and blankets provided for comfort. Pt moved to unit and loaded w/o incident. Pt vitals obtained and noted above. Pt breath sounds obtained and noted. Pt resting comfortably during xport with no problems noted. Upon arrival at dialysis, pt removed from unit on FW. Pt placed into dialysis chair via sheet lift x 2 EMS. Pt belongings left on pt's lap, care xferred to staff, report to nurse."

This is how I've done most of my routine transfer PCR's. If anyone has suggestions or constructive criticism, I'm more than open to listen. Epi, hope this helps your friend...

 

[MMiz]

You'll find people do them a million ways. While what I've written looks like a lot, there are a ton of abbreviations for almost all words I've written. Make sure that if you use an abbreviation, it's an accepted medical abbreviation.

We were required to do something like:

B123 dispatched priority 1 to 123 main street for a "_________." ATF one male patient, later identified via ID as the name above, in the _____ position.
(C) Pt complains of _____________.
(H) Pt history and medications, learned by ________, listed below. Additionally, ______________________
(A) (General appearance of pt noted. Pt. AOx3. Pt. was either + or - for "pain." Then pt. was either + or - for: head pain, neck pain, chest pain, abdominal pain, pain in arms and legs. Pt was either + or - for nausea/vomiting. Pt vitals and condition monitored as noted below. Of course this section could be much more detailed, but this was usually enough for a BLS transfer.
(R) Pt. positioned in position of comfort. O2 via NRB @ 2 LPM. (etc.)
(T) Pt moved to stretcher via sheet drag from hospital bed. Pt secured with straps X3, rails raised. Pt secured in ambulance. Vitals and condition monitored during transport. Pt transported without incident or change in condition. Pt moved to ______ via ____. Pt belongings bag left _____. Full report given to staff.

 

[Ridryder911]

Good points MMiz. Not only approved medical abbreviations, but the local EMS approved abbreviations. These are what your PCR will be judged upon.

R/r 911

 

[DisasterMedTech]

I know that here in IL, to whatever level of success, we are trying to get away from abbreviations, even commonly used ones. It really doesnt take that much more to type "treatment" than it does "Tx" and in spelling things out we can make sure that at least that hasnt contributed to foul ups and mistakes down the line. I would hate to have to sit in court and be grilled by a lawyer as to whether I thought my string of abbreviations has added to any confusions. Ive seen chief complaint as CC, CO (complaining of) PCO (patient complains of) and C with a line over it. I know one medic who writes the clearest run and PCR reports I have ever seen. They are boring as sin to read but everything is there and could be understood by a lay person. And he has never been called for failure to document or confusion caused by the way he writes. I think some providers get caught up in the idea that abbreviations, 10-codes and symbols make them seem more professional and high speed.

 

[MMiz]

I know that here in IL, to whatever level of success, we are trying to get away from abbreviations, even commonly used ones. It really doesnt take that much more to type "treatment" than it does "Tx" and in spelling things out we can make sure that at least that hasnt contributed to foul ups and mistakes down the line. I would hate to have to sit in court and be grilled by a lawyer as to whether I thought my string of abbreviations has added to any confusions. Ive seen chief complaint as CC, CO (complaining of) PCO (patient complains of) and C with a line over it. I know one medic who writes the clearest run and PCR reports I have ever seen. They are boring as sin to read but everything is there and could be understood by a lay person. And he has never been called for failure to document or confusion caused by the way he writes. I think some providers get caught up in the idea that abbreviations, 10-codes and symbols make them seem more professional and high speed.

I always thought that a c with a line over it stands for "with."

 

[reaper]

I write all my reports with as little abbreviations as possible. I still use some common ones, but mostly spell it out. I have learned that it has helped keep me out of court a number of times. I have had lawyers call me and tell me that they were going to subpoena me for court, Till they read my PCR. They said it was the easiest to read, that they have ever dealt with.

I try to make my PCR as easy as possible for any lay person to read and understand. I also do not use a lot of medical terms, as others do. This makes it easier for grandma to read and understand, after we transport grandpa and he dies.

Always remember that a PCR is public record.If you work for a gov. service. You can request anyones PCR. They just black out all personal info on pt.

 

[Ridryder911]

I always thought that a c with a line over it stands for "with."

It does.

The main reason I use abbreviations is because I have about ten lines in a 3 inch square to fill in my narrative. (We have not went e-pcr yet, will soon). As well, there are definite times abbreviation is helpful for example; writing out Penicillin versus PCN, or Nitroglycerin versus NTG, and lung sounds clear to auscultation bi-laterally versus C/T/A bi-lat., or abdominal aortic aneurysm versus AAA.

I believe they are adequate if used properly. What is lacking in EMS is most have never attended medical terminology or charting courses. One can definitely see the difference when comparing to those that have.

I agree, sometimes they are misused or more of what I have noticed "made up" and not actually an approved abbreviation.

R/r 911

 

[emt/ff71185]

A terminology course should be either required separatly or maybe incorporated into the emt-b course at the very least. Being a new emt, I find that a lot of what we learn comes not from the class but on calls. Although I agree that experience is a great thing and of course we will learn by doing it sometimes bothers me that I'm learning on a real life person that called for an expert and is receiving essentially a traniee.

 

[BossyCow]

When writing a report, I try to make sure that I have checked for all the signs and symptoms of the medical issue listed as my 'rule out'. Also, everything in the tx plan should be based on something seen in the P.E. If I put O2 on a patient, where in my report does it show that this was needed? O2 sat? Cap refill? Skin color?

If I put down rule out diabetic emergency, does my meds list include diabetes meds? Do I have something in the subjective that a family member said there was a history of diabetes?

Finally, reports should read like a story, the MPD, reading it a week later, not having seen the pt, should be able to understand what happened on the call and why things were done the way they were. It should answer those questions that the doc would ask you in the ER.

I do use the SOAP format, just because that's what I was trained on. I've found a lot of new EMT's seem to have the greatest difficulty figuring out what is subjective and what is objective. I tell them that if they didn't see it, touch it, or do it, it goes under subjective.