EMS patient narrative

[FiremanLyman]

Thought I would share a tool I use. It is the EMS patient narrative template that I made. We write our patient narratives in the CHAT format. This template uses grey fill-in boxes where one can input a value. Wanted to see if anyone else had some templates they used, maybe steal some ideas from each other. Anything to make report writing easier.

[zzyyzx]

Not a bad template at all. Our reports state most of that stuff before we get to the narrative and we don't repeat the information to keep it shorter. Our narrative basically paints the picture we can't accomplish on the rest of the report. However, if I have a slower shift, I might fiddle with something like this for my own use. Wouldn't be bad to have at all. Thanks for the idea.

[GMANCFD]

A- Arrive on scene what did you find
C- Chief Complaint
H- Patient Medical history and history of incident
A- Patient assesment
R- Treatment
T- Transport

[Mommy_Medic]

I used to work full time at an ambulance service that used a software called Narrativepro that worked with our ePCR. I really liked it cause it used a chronological/CHART format, but you could do SOAP as well. Compared to some of the other narrative generators i have played with, this one allowed me to enter my own words and really tweak the narrative.....

not sure if the program is still out there...but worth a shot

Hope that helps

[BoxAlarm187]

CC: Chief Complaint
HPI: History of Present Incident
PMH: Pertinent Medical History
PE: Patient Exam
TX: Treatment
RTT: Response to Treatment

[oregonFF1]

We use the SOAP format here

Subjective - arrival, who you talked to, what the CC is, your surroundings,
Objective - patient assessment findings, vitals etc,
Assessment - what you believe the source of the problem is,
Plan - what interventions you will implement (or have already).

Sounds far different than what you guys are talking about. But I've found it really speeds up writing reports after the call.

[emt161]

History of Present Illness/Injury: all subjective info regarding chief complaint- patient statements/answers to EMS questioning, witnesses/bystanders, OPQRST, etc

Physical exam: all objective findings except for vitals.

Treatment: Duh. Reaction to treatment if I have room, otherwise it can go in a field corresponding to vitals signs towards the bottom.

Medical history, meds, allergies, and vitals all have their own fields on our paper forms. putting it into the narrative is a waste of space and time.

[palmer1121]

My department is apparently different than most of the above replies... We are a combined fire/EMS department.

If Im on the Medic Unit we use a state sponsored PCR system and write a full EMS PCR. Some use SOAP, SOT, CHART, etc. I personally use a chronological narrative style, Ive just found that it works better for me.

If I'm on the engine and do a Firehouse report for a medical I use a very generic, very basic narrative:

E### responded to medical call at above location. FF/EMT ____________ began patient assessment and care until arrival of Med ###. Upon arrival of Med ### patient care turned over to Paramedic __________. Assisted Med ### with further patient care, assessment and preparation for transport. Med ### patient loaded, transported to XYZ Hospital. E### returned to service. See EMS PCR #123456 for further.

Obviously it is altered slightly for refusals or if I ride in with the Med Unit. The first department I worked for was sued for HIPPA violations and I was taught not to never include any patient vital signs, assessment findings, or names since NFIRS reports fall under open records.