PT Treatment, Care, and PRC writing tips

[Emsbuff124]

Hey, Names eddie im a 21 year old N.Y. EMT before that i was a NY CFR, Ive been working in the back of buses since i was 15 years old and i love it to death everytime i get in the back of the rig. I cannot imagine me doing anything else.
Over the years ive devoloped a way of treating the sick and injured and writing a pcr to conisided with it and ive coached serval people and give them tips on how to treat such matters and i thought finally i like to publish it on a forum and share it with the international EMS community.

First off dispatch- Dispatch can tell you alot about a call and what you should expect and perpare to see and what you should bring in with you first when you kick the the door in ( well not litterally kick the door in you all know what i mean)
Example- Such and such ambulance respond to ridge road for a 65 year old male experience chest pain and diff breathing
you can narrow done that this call 85% this will be a medical call so your probably leave the trauma kick in the truck( unless he got the chest pain from blunt force trauma) and bring in the 02 kick and AED if you are an als truck then you als supplies as well.
The same goes for a car accident with this type of "trauma call you should bring along your trauma kit back board etc etc.

Pt contact- This part of the job always can get me agervated. Time and time agian i see to many emergency workers arive on seen and are ether dis-intrested in the problem the PT is having, argervated ( 3am high B.P. job), or completely disconect from how the PT is feeling.
Compassion in my opinion is the number one key to helping a PT and understanding the problem that they are having, and i achieve this in several ways first off
Connect to the PT. and try to understand the problem that they are having by placing yourself in there shoes. example
75 year old female complaining of body weakness for the past 5 days. She also lost her husband 1 week prior as stated by a CFR on scene. Instead of saying oh shes just faking it, or shes fine this is all total BS why did she even call. Try placing yourself in her shoes, how would you feel if you lost a love one you know for most of your life. how would you feel if now you have a big empty house with no one to talk to, enjoy dinner with, or wake up to in the A.M.
by placing yourself in the PTs shoes you can understand the pain they many be having, or how to better assist them.
Do not get upset- Yes i do it we all do it but :censored::censored::censored::censored::censored: about the call when you are back at the station or in your truck heading back from the hospital. Not in the E.R. or E.R. ems room and god forbid in front of the PT. I dont know how many times i have heard of PT. telling me i should have called your earlier, or i really didnt want to call you because i didnt want to be a pain in the neck. If the call is total BS do it with a smile and dont :censored::censored::censored::censored::censored: because i had a stroke PT once that wait almost 12 hours to call 911. The reason being the last time she went the EMT in charge told her she need a taxi and not ems. My point being the call may be BS. but next time they could be having a heart attack and not call because there dont want to be a baby or pain in the butt.
PRC
The wonderful report we all have to right i have a method that works for me all the time and gets the job done and here it is
Start for the head and work down and then foccus on the problem at hand
here is a quick way i would write one
situation-
male 75, sitting in chair on first contact, chest pain, radiating down his right arm
here goes
U/A found 75 year old male sitting in chair in kitchen. PT states he has being having chest pain for last 15 minutes. PT is A+0X3 (alert and oriented), CMSx4 (circulatory, motory and sensory same as PMS), PEARLA+ ( pupils equal, and round to lights and accomidation), + chest pain, - sob (sortness of breath), HEENT ( head ears eyes nose and throat ) is clear and free of fluid) -JVD, -TD ,lungs clear=, ABD sort and non tender. PT reports -loc, - vomiting, - blurr vission, + radiation down right arm. Pt describes pain as a 10 on 10 decribed as crusting dead center chest pain. Pt reports cadiac history, Pt Txd to rampard genral hospital report given to E.R. nurse pt left treatment room one with no change in status.
As shown above my report is not perfect but is clear in my opinion and have a well written clear pcr keeps you out of court because judges and lawers can better read it if need be.
Remember when writing the report do it at the hospital or half way to the hospital not while the PT is talking to you. By writing a report during PT care shows the PT that you really dont care what they have to say. EMS lounges are for report righting not ambulances.
Finally when you give a report at the nurses station do not tell the nurse 75 year old female with chest pain. To me by doing that it makes it like the PT isnt human and they really dont matter instead try this. This is miss joans she is 75 years old and she is having chest pain today. By doing this the PT feels as if their needs matter to the nurses and doctors that are going to take care of them.
Finally remember if your having a bad week keep it home, or at the station door, but dont bring it with you on a call. If your really stressed take a day off if you can, and if need be talk to a person about your issues because your well being and mental health comes first before anything


thanks again for reading my post, and feel free to add or sugjest anything
EDDIE

 

[RyanMidd]

This looks very familiar to PCR formats found in our textbooks, meaning you have a good PCR standard.

However, I hope your spelling by hand is better than your typing, or I'd hate to be the receiving medic of your paperwork =P

 

[Emsbuff124]

I know i know im told that alot thats why i try to use short hand and not use big words but thanks for the compliement, i try to treat all my PTs as humans and not a sorce of income, or and animal with no feelings

 

[JPINFV]

If I were ever to work as an EMT again, my PCR format would be as followed:

PSOAP[delta]

Prearrival (dispatched to a... any problems/delays in route)

Subjective: C/C, history of present illness (including OPQRST), medical history, surgical history, allergies, medications, family history (if applicable), social history (alcohol, tobacco, recreational drug use, sexual history as applicable), review of systems (e.g. Do you have any chest pain, neck stiffness, etc).

Objective: Physical exam, starting from the head and working down.

Assessment: Working/differential diagnosis(es) (if you are under a strict protocol system, you can use the protocol(s) you're working under)

Plan/[delta]: Treatment plan, patient's response to treatments (if any), and any additional interventions due to changes.

Similarly, it's not terrible to fill out your PCR as you get information. You aren't going to remember all of the patient's medical history, allergies, and medications until your at the hospital. When I'm working with the standardized patients, I normally start the encounters along the lines of, "Hello, I'm JPINFV, your first year medical student. What's your name? Is it ok if I call you ____? What brought you in today? Is it OK if I take some notes as I ask you questions so that I can remember everything? (and move on into the subjective)"

Similarly, I generally start my social history (drugs, alcohol, tobacco, and sexual history. Females with ABD pain and anyone with GU/pelvic/reproductive complaints should ideally have a sexual history obtained at an appropriate and private time), "I'm going to have to ask you some personal questions. Everything will remain private, but is important." Ask the questions nonchalantly in a manner like how you would ask any other question ("Do you have any allergies?" shouldn't come off any differently than "Are you sexually active? Men, women, or both? One partner or many? Do you use protection?").

 

[Emsbuff124]

above me

Yeah i like your aproach as well its systematic and thought out ive seen PCRs were there the start with the head move to the feet focus on the presenting problem, then the dispatch info it turn into a snow ball wreak at times very confusing

 

[JPINFV]

Well, SOAP notes is the standard for medical history and physical documentation. The thing is to adapt it to EMS. Documentation just needs to be taught properly and drilled into students. In this semester alone, my class has had to write 3 subjective notes on SPs and 3 subjective/objective notes on 3 SPs. The 6 notes collectively are something around 75% of our grade in that course.

 

[Emsbuff124]

correct i agree being ive seen a PCR once were the person just put pt complaining of chest pain, pt txt to er and that was it

 

[emt1972]

If I were ever to work as an EMT again, my PCR format would be as followed:

PSOAP[delta]

Prearrival (dispatched to a... any problems/delays in route)

Subjective: C/C, history of present illness (including OPQRST), medical history, surgical history, allergies, medications, family history (if applicable), social history (alcohol, tobacco, recreational drug use, sexual history as applicable), review of systems (e.g. Do you have any chest pain, neck stiffness, etc).

Objective: Physical exam, starting from the head and working down.

Assessment: Working/differential diagnosis(es) (if you are under a strict protocol system, you can use the protocol(s) you're working under)

Plan/[delta]: Treatment plan, patient's response to treatments (if any), and any additional interventions due to changes.

Similarly, it's not terrible to fill out your PCR as you get information. You aren't going to remember all of the patient's medical history, allergies, and medications until your at the hospital. When I'm working with the standardized patients, I normally start the encounters along the lines of, "Hello, I'm JPINFV, your first year medical student. What's your name? Is it ok if I call you ____? What brought you in today? Is it OK if I take some notes as I ask you questions so that I can remember everything? (and move on into the subjective)"

Similarly, I generally start my social history (drugs, alcohol, tobacco, and sexual history. Females with ABD pain and anyone with GU/pelvic/reproductive complaints should ideally have a sexual history obtained at an appropriate and private time), "I'm going to have to ask you some personal questions. Everything will remain private, but is important." Ask the questions nonchalantly in a manner like how you would ask any other question ("Do you have any allergies?" shouldn't come off any differently than "Are you sexually active? Men, women, or both? One partner or many? Do you use protection?").

SOAP is the common one, one that I learned working as an EMT is CHATR

Chief Complaint
History
Assessment
Treatment
Response to treatment

 

[daedalus]

Sorry, SOAP is the standard for medical documentation. Exactly as described by JP.

I never understood why every FTO likes to teach documentation their own special way.

 

[JPINFV]

To be fair, I think that SOAP in it's purist form is inappropriate for EMS. Using just[/b] subjective, objective, assessment, plan, there's no place to put the specifics of EMS (e.g. prearrival issues, hence my extra P section) and the rapid changes that are going to occur with treatment (hence my "delta" section). It's great for chronic plans where the changes are going to occur over hours (progress notes) or longer (where a new SOAP note may be needed). Similarly, since charting isn't really taught in class, when told to write a story, a narritive format (like I used to use) is the easist to pick up. SOAP formatting isn't the most logical format when making a format from scratch, however once used to writting in the format, it is an easy format to adapt.

 

[Aidey]

To the OP, your overall form looks ok. Using abbreviations and short hand is no substitute for good spelling, grammar and punctuation though.

When it boils down to it, CHART and SOAP really end up looking the same.

The CH is the S, the A is the O, and the RT is the P.

CHART = CC, Hx, Assessment, Rendered Care, and Transport
SOAP = Subjective, Objective, Assessment, Plan

I personally like CHART for pre-hospital because I think it fits what we do in pre-hospital better. For example, the transport section, which isn't really needed for a patient who is in the hospital already.

I do have a huge pet peeve with the way we are usually taught to document in the Chief Complaint section, no matter what method of documentation is being used. It really is a semantics issue, but it still bothers the heck out of me.

CC: Unconscious
CC: Diarrhea (6 mo baby)
CC: UTI (90 year old aphasic dementia patient)

None of those are actually complaints because none of those patients can state a complaint. Each thing listed is actually the patient's presenting problem. I hate it when I see stuff like that in a PCR because it technically isn't accurate. Because of this I usually put "CC/Presenting problem" as my first header rather than just "CC".

 

[JPINFV]

First, I'd argue that diarrhea is a CC since the parents would be presenting a CC.

Second, one of the nice things about SOAP is that it isn't just SOAP. There's an internal configuration that helps to split up the assessment into logical chunks. Now not everything is needed on all (or even most) EMS runs, but having it there helps to make sure that nothing is missed while the lesser used areas can be added with ease.

S:

• History of present illness
• Allergies
• Past Medical History
• Past Surgical History
• Medications
• Social History
• Review of Systems:
  1. General
  2. HEENT
  3. Neck
  4. CV
  5. Resp
  6. ABD
  7. GU
  8. Muscular-skeletal
  9. Skin
  10. Psych
  11. Neuro

Objective (physical exam) is similarly divided into a list like ROS.

 

[daedalus]

S:
Dispatch Info (it is subjective because of the EMD interview)
c/c
HPI (OPQRST)
and then the"sample"
Allergies
Medications
Past Hx (including family, social, medical, and surgical)
Last oral intake if appropriate (including fluid intake prn)
Review of systems (is there nausea, vomiting, changes in bowel habits, or possibility of pregnancy with that abdominal pain?)

O:
Vitals, PE, EKG, etc

A:
"treating for possible acute abdomen"

P:
"IV TKO, 2LPM O2 via NC, Morphine 2 mp IVP, transport to ED code 2"

 

[Aidey]

JPINFV - I can kind of see what you mean, but in that case it is the parent's complaint, not the patient's. Like I said, it really is a semantics thing.

To me "Chief Complaint" is what your patient says is the problem in their own words. If the patient can't communicate their complaint, writing "Chief complaint: XYZ" is putting words in their mouth. Hence why I like adding presenting problem in there. That way I'm protecting myself from accusations that I documented the patient saying something they never did.

Presenting problem also works well for when the issue is a diagnosis rather than a symptom, which mostly pops up during transfers. Say you are transferring a MI patient/ Chest pain is their complaint, but Acute MI is the diagnosis necessitating the transfer.

Am I making any sense? I don't feel like I'm explaining myself well.

 

[trevor1189]

I have a saved template that I use. I just modify things I need to as I go. Here is an example for a CP call.

On December 16th 2009 at 02:59 hours, Ambulance # was dispatched to 123 Main Street, City, State, Zip Code by the (Insert Name) County Communications/911 Center for Chest Pains. Ambulance # responded under emergency conditions with the use of lights and sirens.

HPI: Upon arrival 86 YOM was found lying supine in bed complaining of midsternal CP and dyspnea. Pt. Rates pain 9/10 of the pain scale and states that it has been constant since lunch at 13:30 hrs. Pt. Called 911 when he began having trouble breathing.

Initial Assessment:

Airway: Self maintained. Breathing: Adequate rate and depth. Circulation: Radial pulses strong/= bilaterally, tachy @ 135 bpm.

Physical Assessment:

Head: No trauma noted, no fluid drainage from Eyes/Ears/Mouth/Nose. Pt. Denies any dizziness, blurred/double vision, headache, syncope. Pupils: PERRL. Neck: Trachea midline, (-) JVD. Chest: Breath sounds present, equal and clear in all fields bilaterally. Tachypenic at 33 bpm. ABD: ABD is soft, non tender, (-) guarding, (-) rebound, (-) masses. Pt. Denies any N/V. Pelvis: Unremarkable. (-) incontinence. Extremeties: Normal muscle tone, CSM +/= in all extremities. Skin: Pale, Warm, Diaphoretic. Mental Status: Pt. Is AA&Ox4, GCS 15. Cincinatti Stroke Scale: (-)

Past Medical Hx:
MI, Angioplasty 2007, Angina, Anxiety

Medications:
Coumadin, Lipitor, Lorazepam

Allergies:
Latex, PCN

Treatment/Transport:
Pt. assessed. O2 applied @ 4 L/min NC. Pt. Tolerates O2 well with no complications. Pt. States O2 is helping with the difficulty breathing and CP. Vital signs assessed (see flow chart). Pt. Assisted from bed to litter and secured with three straps. Pt. Loaded into ambulance. Pt. Transported in Semi-Fowler's position to the hospital. ALS interventions by Medic #. Vital reassessed periodically (see flow chart). (Name) hospital contacted by cellular phone to advise pt. Status. Ambulance X arrived at the (Name) Hospital. Pt. Taken to bed 1. Verbal report given to ED RN. Care transferred.

Additional Notes:
Pt. last seen at (Name) hospital in bed 1 with ED RN in improved condition.

End of PCR.

Trevor1189, EMT-B 123456

 

[emt1972]

Good discussion going here. Everyone has their ways of remembering/charting and so long as the pertinent is done, no matter whether it SOAP, CHART, CHATR or whatever... that is the most important thing.

Happy Holidays All

 

[Danson]

As a new EMT-B soon to enter the work force, this post and comments were very helpful! I hear stories all the time about how some EMTs/Medics become disinterested with the PT, sometimes to the point of being rude or downright mean. I have vowed to never become this way. Acting that way would be doing the exact opposite of the reason that I am going into this field.

As for report writing, we were never taught that in my EMT class. Are there some exersizes that I can do to get comfortable with this skill, or does it just come with time on the job?

 

[CAOX3]

I have a saved template that I use. I just modify things I need to as I go. Here is an example for a CP call.

On December 16th 2009 at 02:59 hours, Ambulance # was dispatched to 123 Main Street, City, State, Zip Code by the (Insert Name) County Communications/911 Center for Chest Pains. Ambulance # responded under emergency conditions with the use of lights and sirens.

HPI: Upon arrival 86 YOM was found lying supine in bed complaining of midsternal CP and dyspnea. Pt. Rates pain 9/10 of the pain scale and states that it has been constant since lunch at 13:30 hrs. Pt. Called 911 when he began having trouble breathing.

Initial Assessment:

Airway: Self maintained. Breathing: Adequate rate and depth. Circulation: Radial pulses strong/= bilaterally, tachy @ 135 bpm.

Physical Assessment:

Head: No trauma noted, no fluid drainage from Eyes/Ears/Mouth/Nose. Pt. Denies any dizziness, blurred/double vision, headache, syncope. Pupils: PERRL. Neck: Trachea midline, (-) JVD. Chest: Breath sounds present, equal and clear in all fields bilaterally. Tachypenic at 33 bpm. ABD: ABD is soft, non tender, (-) guarding, (-) rebound, (-) masses. Pt. Denies any N/V. Pelvis: Unremarkable. (-) incontinence. Extremeties: Normal muscle tone, CSM +/= in all extremities. Skin: Pale, Warm, Diaphoretic. Mental Status: Pt. Is AA&Ox4, GCS 15. Cincinatti Stroke Scale: (-)

Past Medical Hx:
MI, Angioplasty 2007, Angina, Anxiety

Medications:
Coumadin, Lipitor, Lorazepam

Allergies:
Latex, PCN

Treatment/Transport:
Pt. assessed. O2 applied @ 4 L/min NC. Pt. Tolerates O2 well with no complications. Pt. States O2 is helping with the difficulty breathing and CP. Vital signs assessed (see flow chart). Pt. Assisted from bed to litter and secured with three straps. Pt. Loaded into ambulance. Pt. Transported in Semi-Fowler's position to the hospital. ALS interventions by Medic #. Vital reassessed periodically (see flow chart). (Name) hospital contacted by cellular phone to advise pt. Status. Ambulance X arrived at the (Name) Hospital. Pt. Taken to bed 1. Verbal report given to ED RN. Care transferred.

Additional Notes:
Pt. last seen at (Name) hospital in bed 1 with ED RN in improved condition.

End of PCR.

Trevor1189, EMT-B 123456

Wow very thorough.

 

[trevor1189]

Wow very thorough.

We use EMStat 5 and a lot of people have templates saved. When I got my EMT-B, I copied and pasted parts to make my own. Something that might work for you.

 

[mcdonl]

Just Learning....

I am an EMT student, and we had to do an assesment and PCR for homework this week. I will not show you mind :wacko: but I will show you what one of our medics provided me for feedback when he completed the same note, based on the information I gave him. I chose do do a narrative, which left too much room for error... he uses what looks like a modified SOAP note...

Called to the residence of a 40 yo(F) who has c/o shortness of breath and chest pain. Pt reports sudden onset of left sided chest pain and shortness of breath, while carrying laundry up and down stairs, it gets worse with activity and nothing relieves it fully, pain is sharp in nature, and radiates to jaw and left upper extremity, pain is 6/10, it started around 1700. Pt reports she sat down thinking it would go away but when it didn’t she called 911.Allergies: NKDAMeds: Cholesterol lowering medicationPMHX: None

Adult female found sitting at kitchen table, appropriately dressed for inside temperature. House appears well kept , food noted on stove cooking ( this is more pertainent, when dealing with a person found outside, or in cases in which you question if a person is able to take care of themselves, ect, but put it in as example)

LOC: Alert and orientated to time, place, events Color: PaleSkin: Warm and moist HEENT: (this is head,ears,eyes,nose,throat) PERRL, No JVD, Trachea Mid line Chest: Breath sounds clear and =, Mild Supraclavicular retractions Abdomen: SNT x4Extremities: Moves all spontaneously, CSM intact, No pedal edema, = grip strength Back: ( I would leave this out in this case but should be there in the case of a trauma with potential for spinal injury) Palpated spininous processes cranium to sacrum, no tenderness to palpation, no deformity noted.

Perninent vitals: HR: 65 regularly/regular, BP: in sitting 117/70, RR: 24 regularly/regular, O2 sat: 95 RA, 100% on O2 6lpm via NC, Temp: 98.8 TympanicP: Assessment, O2 via NC 6lpm, Called for ALS, Administered Asprin 326mg PO, Transferred to stairchair and moved to rescue, Transport, Monitored vitals, Finger stick blood glucose: 120, Paramedic Onboard, Report to Paramedic, Turned over care and Assisted as requested.

A; R/O Myocardial Infarction

GodIhope Ipass, EMT-B