This is a follow-up post to my previous piece on EMS narrative Reporting, EMS narratives, paramedic and EMT narrative reports and the like. I have more, you can see them here:

Soapy Pictures – The EMS Narrative Report

Six Tricks You Can Use Today to Improve your EMS Narrative Report

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The narrative is the most useful component of the EMS patient care report. It is the part of the report that is actually read, understood quickly, and most useful to the humans who have to act on the information provided in the patient care report. Humans don't process the information gathered by all of the check boxes and drop-down menus very well. If you've ever had to read many patient charts you'll quickly understand why. The check boxes and menus store information in a way that is good for computer processing and statistical analysis, but not for rapid human comprehension. A good EMS Narrative report is a short story that explains the events of the call, the decisions made on the call by the paramedics and/or EMTs, the information available to the paramedics/EMTs that they acted upon to make the decisions they made, and the outcome of those decisions. It should also "Set the scene" for the reader, and explain the circumstances of the call, the events leading up to the call, the way that the call was handled, and provide enough information so that anyone reading it gets a good sense of all of the information gathered by the EMS people who were there. I don't advocate the use of automatic narrative generators as included in some software packages, because computers can't write something that humans usually find useful.

Think about it this way, you're writing your narrative reports for these audiences:

• Healthcare providers farther down the line who will be taking care of the patient after you transfer patient care – These people are not just the Nurses and Doctors at the ER who you leave your patient with. Your PCR (in most areas and if it isn't this way in your area it should be) is part of the overall patient chart and is the best window to the patient's initial presentation when their condition is in its most acute stage. Remember, EMTs and Paramedics are "The eyes and ears of the physician" at an emergency scene. A good EMS narrative report on your PCR provides that view of the patient to every healthcare provider who takes care of the patient, including the patient's primary care physician and any specialists that care for the patient later. I've seen many times where a quick-thinking paramedic was able to obtain an EKG strip and a good assessment during a patient's undiagnosed episode of tachycardia and write a good narrative explaining their assessment findings which then enabled a cardiologist to immediately make a diagnosis and save the patient weeks of wearing a Holter monitor to try and reproduce the rhythm for a diagnosis.

  In addition to all of the above, you will be judged on the quality of your narrative by the healthcare providers down the line, your service will be judged, and our profession will be judged. If you write a narrative report that is full of poor grammar, misspelled words, nonsensical statements, and other gobbledygook, other healthcare providers will think you're an idiot. If they see your reports as inferior to other service's reports, they'll think your service is a bunch of idiots. They may even think that all EMTs and paramedics are complete nincompoops. I've heard complaints that the ER people never read the patient care reports that ambulance crews leave for them. Maybe it's because they have read too many of them that are complete nonsense. Rite dem gud reports gize!

• Your Management and Your Medical Director – A good EMS Quality Assurance/Quality Improvement program is impossible without good EMS reporting. It isn't about a game of "Gotcha!". It's about documenting how protocols, procedures, policies, and operations really work in the field. If you have a patient that the medical director follows up on after their care in the ER, the first thing that he or she is going to do is read your narrative to find out what you did, what protocol you followed, and why you did it. If you paint them a good picture, they may find the information useful enough to be able to tweak protocols and fine-tune procedures. Sure, you may get a talking-to occasionally, but a well-documented call that doesn't quite go to plan is always better than a poorly documented call that doesn't go according to plan. You're protecting yourself and your crew. If everyone writes a good narrative, everyone is working to improve patient care.

• Lawyers – Who didn't see this one coming? It's not my quote, but I've said it before and I'll say it again: "If you didn't write it, you didn't do it… unless it was bad. Then, if you didn't write that you DIDN'T do it, you did do it". EMS people get sued sometimes. Nice, caring, professional, and compassionate people get sued sometimes. It often doesn't make sense why, either. I wouldn't say that there is an epidemic of lawsuits against individual providers or ambulance services, but it can and does happen more often than we want it to. Writing a "LEGALLY DEFENSIBLE" narrative report is key. Always do this, read more on this below. However, it's not just lawyers that want a piece of you that read patient care reports. Lawyers that handle civil cases for our patients read them in order to gather information about lawsuits that our patients file. EMS Patient care reports are a wealth of information for civil attorneys litigating workers' compensation cases, car accidents, accidental injuries, and fraud. By not writing good narratives, we can damage our patients' legal cases. By providing factual, relevant information, we can protect the innocent parties in legal cases. If you're ever called to testify in one of these types of cases, you'll appreciate having written a good narrative. Trust me.

• Your Own Backside – Remember what I said above about writing a "legally defensible" narrative? This means that you need to write your narrative in such a way that you look like a true professional in the eyes of the court. Even if you did everything exactly right, if you documented the call like a D-minus third-grade book report on "Snuggles the Wonder Kitten", you're an idiot in the eyes of the jury. The jury, or judge, thinks that idiots are probably negligent. Therefore, people who write bad narratives are probably doing other things badly, and people who do things badly are doing them negligently. It's not a good situation and not one that you're likely to win. I've always said that I will make tough decisions when I have to, and will even bend the rules a bit if it is the right thing to do for the patient. However, if and when you have to do this, make sure that you clearly document:

  Document everything. If it was minus-30-degree weather and it was best for the patient to not put them in a KED because they would be frostbitten by the time you were done, that is information that would help you if they had an occult c-spine fracture from an auto accident. If the patient was trying to knock your teeth out and you restrained them, that is also good information. If you withheld a medication indicated by protocol, say adenosine for a Narrow Complex Tachycardia because you saw a ramp-up (delta wave) between the P-wave and the QRS complex indicative of Wolf-Parkinson-White syndrome where adenosine is contra-indicated, you should probably document that well. Good documentation is documentation that gives a full picture of the scene for those that read your report. Document a full assessment (DO A GOOD ASSESSMENT, then document it). Document your working diagnosis and the differential diagnoses that you considered and ruled-out. Document the treatment you gave per protocol and the response that the patient had to the treatments given. Document how you were dispatched to the call and how you responded. Document information that you gathered from people at the scene, and who those people were. Document what you saw when you arrived on scene. Document more than you think that you should. Make sure that its coherent information. I'm going to harp on this again: By all means possible, USE PROPER ENGLISH, SPELLING, GRAMMAR, and PUNCTUATION! Spell check is a great tool. However, it doesn't differentiate between the RIGHT words for the sentence, and the WRONG words. Your going to be wrong if you re-lie only one spell cheque (Yes, those were the wrong words. No, Spell check didn't catch it. Got it?)

  • The reasons you were in the situation where you had to bend the rules and/or make a tough decision

  • The information you had available to you that caused you to make the decision you did

  • The options you considered that were less desirable than the decision you ultimately made, and why
    they were less desirable

  • Why you felt it was best for the patient, even if and especially if the decision went wrong

  • (Make sure it was the best for the patient)

In the previous post, I spoke about the fact that I use the "SOAP" method to write my EMS narratives. I didn't intend to do it this way, and I used to think that I hated it until I realized that it was what I was using when nobody told me to. "SOAP" is an acronym that describes the "SOAP Charting method" I don't know who came up with it, but the letters stand for "Subjective, Objective, Assessment, Plan" (See HERE to go to the other post to read more on it.) These things help you organize the information in a readable format. I think that they help "set the stage" for the short-story that is your narrative.

Here's two examples of "Subjective" information:

• Ambulance 1-J-26 dispatched emergent through the 911 system to the scene of a two-vehicle MVC with injuries on a two-lane 55mph rural highway. Upon our arrival we found a "head-on" style collision between two late-model pick-up trucks with heavy damage to both vehicles on their front driver's side. Triage was initiated and this Patient (Pt) was identified as critical. There were four injuries on this scene. The Pt in this report was the restrained driver of a late-model pickup truck with heavy front-end damage and intrusion into the passenger compartment. Pt was pinned in the vehicle upon our arrival with his chest set between the steering wheel and the seat. Pt was conscious, alert, and oriented x 2 with labored breathing but no apparent airway compromise. Fire/Rescue notified of the need for heavy extrication and a Med-Pigeon Helicopter was requested for a scene response. Traffic control and the landing zone referred to Anytown Sherrif's Dept already on scene.

• Ambulance 1 dispatched non-emergent for the routine scheduled transfer of the 59yo F Pt from HOLY BEAGLE HOSPITAL –Rm #223 to ST. BERNARD REGIONAL ICU. Upon our arrival we found the Pt's RN who gave us a passdown report on the Pt. Pt had been admitted to Holy Beagle for treatment of an exacerbation of CHF and had been diagnosed with further respiratory compromise related to pneumonia per her physician. Pt was being transferred for ICU care at St. Bernard. Found the Pt Conscious, Alert, and oriented x 2 with ABCs intact.

These are the first type of sentences that I write into my narrative reports. It is "Subjective" information because it sets the scene. It states who you are, how you were dispatched, what you were dispatched for, where you were dispatched to, and what you found immediately when you got there. The second one states who you received information from: The patient's RN. Notice that I put in statements containing the patient's level of consciousness, airway patency, respiratory effort, and circulatory status. I think that this helps to show that you began your assessment immediately upon laying eyes upon the patient.

Continuing, some examples of "Objective" information, continuing on with the two narratives above:

• Pt was still located in the driver's seat and was able to understand that he had been in a severe car accident. Pt had strong and rapid radial pulses noted but had shallow respirations. Pt was unable to tell us what time or what day it was. C-spine precautions were initiated in the vehicle with a c-collar and manual stabilization as fire/rescue extricated the patient. Extrication took approx. 10min. Patient was removed via backboard and secured with straps, head blocks, and tape. Pt secured on cot. Due to 10min ETA from ther responding helicopter EMS and an estimated 30min transport time to a trauma center, Pt was taken to the ambulance for stabilization. Patient with CC (Chief Complaint) of chest pain and dyspnea.

• Pt was sitting upright in her hospital bed. Pt on EKG monitor showing NSR s ectopy. Pt had been given a 20ga IV in her R hand and was receiving an IV drip of 1000ml Normal Saline at 100ml/hr and an IVP drip of Levaquin via that IV site. RN std that Pt had also received an IV bolus of 40mg Lasix approx 20min prior to our arrival as well as 1000ml Tylenol PO for a recurrent fever, last measured at 101.5 degrees. Pt was on o2 at 4-LPM via NC bringing her SpO2 to 98%. Pt had a foley cath in place (thank goodness). Pt was unable to ambulate due to her condition and resultant weakness. Pt secured on cot and taken to rig. Vital signs assessed and per previous in this report (Yes, this is the ONE thing that the check boxes are good for). Pt denied CC other than of being tired.

This is the second section of my EMS narrative report. It is called the "Objective" information because it is information you get through objective observation (think the scientific method). Objective observation is what you observe while you are there when looking at the scene with a trained eye. This could include the initial assessment (or primary assessment, whatever the kids are calling it these days) and a discussion of the life threats or lack thereof that you see. This is information directly gathered by you about the patient.

The "Assessment" portion, and the continued examples from above: (I write "ASSESSMENT" in capital letters in order to differentiate the report. You don't have to, but I just always have)

1. ASSESSMENT: As above. Skin Pale, cool, diaphoretic. Pupils PERRL. No evidence of head trauma. JVD (Jugular Venous Distention) noted. Trachea midline/mobile. Chest with asymmetrical movement to inspirati
   on, markedly decreased breath sounds in both R upper and R lower chest, bruising, abrasions, and what appeared to be a steering wheel imprint left in Pt's chest with other indications of thoracic trauma. ABD tender to palpation in the RUQ and LUQ, not noticeably distended. Pelvis intact. Extrem c weakening peripheral pulses but good motor and sensation. Pt seemed to be becoming increasingly lethargic, confused, and agitated. Pt was loudly complaining of chest pain and diff. breathing, stating that it "hurt to breathe". Pt's Blood Pressure (BP) taken q 5min showed 1^st reading at 134/84, 2^nd reading of 128/92, and 3^rd of 110/98.

1. ASSESSMENT: As above. Skin Warm, pink, and moist. Pupils PERRL, no JVD, trachea M/M, Chest equal rise/fall bilaterally c diffuse rhonchi and rubs throughout. ABD SNT. Extrem c good Pulse/motor/sensation/temp x 4. Some pitting edema noted to both lower extremities. Pt was resting comfortably and std that she "felt much better" after the Tylenol. Pt denied other complaints.

   The "Assessment" portion of the report is the secondary assessment, the detailed assessment, and/or the focused assessment. At a minimum, it should include what are called "pertinent negatives". These are things that you should always put in every report. Detail a head to toe assessment. The "pertinent negatives" as they are called, are negative assessment findings. Even if you don't find anything, you write that you didn't find anything to prove that you looked at it. I think that you should avoid acronyms such as "normal", or WNL (Within Normal Limits) as they prove only that you didn't really look. Normal is a subjective statement. If the skin is pink, warm, and dry, write that. Don't just write "Skin normal", because a lawyer will pick you apart on what "normal" is for that exact patient, and just how exactly you are qualified to know what "normal limits" are for that patient population. I always break the assessment portion into the same format: Skin signs, head, pupils, trachea, JVD/no JVD, Chest condition and lung sounds, Abdominal findings, pelvis (for trauma), then extremities. After that, I write specific assessment findings that don't fit into the above sentence. Feel free to get as detailed as you need to in writing details about the various organ systems. I also write "as above" in the first part in order to tie in any assessment findings that I may have included in the above two sections. This is a very important part of the narrative, write it well.

Finally, the "Treatment Plan" section: (I always write "TREATMENT" in caps, once again, just 'cuz I do)

1. TREATMENT: As above. Pt placed on 15-LPM o2 via NRB while still in the vehicle. Bilateral IVs started with a 14ga in L AC and a 16ga started in R AC. Both IVs running 1000ml warm NS fast TKO. Pt placed on 5-lead EKG showing S-tach (Sinus Tachycardia) with occasional PVCs. Pt's abrasions and various superficial bleeding controlled c gauze and tape. Due to Pt's increasing dyspnea, narrowing pulse pressures, JVD, and decreased breath sounds on the R side a needle decompression was performed in the R upper chest (beween 2^nd/3^rd intercostals) with 14ga IV cath and flutter valve placed. Pressurized air return noted in syringe upon penetration of the pleural space. Note trends of vital signs. Pt's breathing improved markedly and Pt's LOC began to improve. Pt continuously monitored during and after treatment.

2. TREATMENT: All inpatients treatments continued. Pt maintained on o2. Pt maintained on EKG showing NSR s ectopy. Pt rested comfortably during transport without any additional complaints. VS (vital signs) q 15min without change observed.

As far as the "Treatment" section is concerned, write what you did and how the patient responded. For routine treatments, such as oxygen, bandaging, splinting, and an IV, I usually just write that I did them if the patient condition is such that they would be automatically assumed to be done. For more complex treatments, such as medication given or the pleural decompression described above, I document the rationale and the technique used. A good rule of thumb is: The more invasive the treatment, the more you should write why and how you did it. You should also write how the patient responded to the treatment, and if you considered one treatment over another, write that too.

To end my report, I put the patient's disposition. I also include a statement on how I contacted the receiving hospital (in my case) or medical control:

1. Receiving hospital notified of incoming level 1 trauma by MedChannel radio. Med-Pigeon Flight crew arrived and our crew assisted in packaging the patient. Handed over Pt care to flight crew and assisted with transporting the Pt to the waiting helicopter. Care transferred.
2. Pt transported and transferred to St. Bernard ICU RN staff s incident or exacerbation of condition.

   The above statements concern what you ended up doing with the patient. Always show that you passed the patient to an equal or higher level of care. Show that it was an orderly and legal transfer. If you are calling into the base hospital or medical control, state any orders received and who gave them to you ("Formerly St. Hospital contacted via MedChannel with orders received to administer 1 amp D-50 per Dr. Marcus. Order confirmed. 1 amp D-50 given per the order"). If you receive no orders, write that too. I always include the phrase "Pt transported and transferred (to whom) s (which means "without" in case you were wondering) incident or exacerbation (which means, "to get worse") of condition".

Now, let's bring together the reports #1 and #2 so you can read them as a whole:

1. Ambulance 1-J-26 dispatched emergent through the 911 system to the scene of a two-vehicle MVC with injuries on a two-lane 55mph rural highway. Upon our arrival we found a "head-on" style collision between two late-model pick-up trucks with heavy damage to both vehicles on their front driver's side. Triage was initiated and this Patient (Pt) was identified as critical. There were four injuries on this scene. The Pt in this report was the restrained driver of a late-model pickup truck with heavy front-end damage and intrusion into the passenger compartment. Pt was pinned in the vehicle upon our arrival with his chest set between the steering wheel and the seat. Pt was conscious, alert, and oriented x 2 with labored breathing but no apparent airway compromise. Fire/Rescue notified of the need for heavy extrication and a Med-Pigeon Helicopter was requested for a scene response. Traffic control and the landing zone referred to Anytown Sherrif's Dept already on scene. Pt was still located in the driver's seat and was able to understand that he had been in a severe car accident. Pt had strong and rapid radial pulses noted but had shallow respirations. Pt was unable to tell us what time or what day it was. C-spine precautions were initiated in the vehicle with a c-collar and manual stabilization as fire/rescue extricated the patient. Extrication took approx. 10min. Patient was removed via backboard and secured with straps, head blocks, and tape. Pt secured on cot. Due to 10min ETA from ther responding helicopter EMS and an estimated 30min transport time to a trauma center, Pt was taken to the ambulance for stabilization. Patient with CC (Chief Complaint) of chest pain and dyspnea. ASSESSMENT: As above. Skin Pale, cool, diaphoretic. Pupils PERRL. No evidence of head trauma. JVD (Jugular Venous Distention) noted. Trachea midline/mobile. Chest with asymmetrical movement to inspiration, markedly decreased breath sounds in both R upper and R lower chest, bruising, abrasions, and what appeared to be a steering wheel imprint left in Pt's chest with other indications of thoracic trauma. ABD tender to palpation in the RUQ and LUQ, not noticeably distended. Pelvis intact. Extrem c weakening peripheral pulses but good motor and sensation. Pt seemed to be becoming increasingly lethargic, confused, and agitated. Pt was loudly complaining of chest pain and diff. breathing, stating that it "hurt to breathe". Pt's Blood Pressure (BP) taken q 5min showed 1^st reading at 134/84, 2^nd reading of 128/92, and 3^rd of 110/98. TREATMENT: As above. Pt placed on 15-LPM o2 via NRB while still in the vehicle. Bilateral IVs started with a 14ga in L AC and a 16ga started in R AC. Both IVs running 1000ml warm NS fast TKO. Pt placed on 5-lead EKG showing S-tach (Sinus Tachycardia) with occasional PVCs. Pt's abrasions and various superficial bleeding controlled c gauze and tape. Due to Pt's increasing dyspnea, narrowing pulse pressures, JVD, and decreased breath sounds on the R side a needle decompression was performed in the R upper chest (beween 2^nd/3^rd intercostals) with 14ga IV cath and flutter valve placed. Pressurized air return noted in syringe upon penetration of the pleural space. Note trends of vital signs. Pt's breathing improved markedly and Pt's LOC began to improve. Pt continuously monitored during and after treatment. Receiving hospital notified of incoming level 1 trauma by MedChannel radio. Med-Pigeon Flight crew arrived and our crew assisted in packaging the patient. Handed over Pt care to flight crew and assisted with transporting the Pt to the waiting helicopter. Care transferred.

    

2. Ambulance 1 dispatched non-emergent for the routine scheduled transfer of the 59yo F Pt from HOLY BEAGLE HOSPITAL –Rm #223 to ST. BERNARD REGIONAL ICU. Upon our arrival we found the Pt's RN who gave us a passdown report on the Pt. Pt had been admitted to Holy Beagle for treatment of an exacerbation of CHF and had been diagnosed with further respiratory compromise related to pneumonia per her physician. Pt was being transferred for ICU care at St. Bernard. Found the Pt Conscious, Alert, and oriented x 2 with ABCs intact. Pt was sitting upright in her hospital bed. Pt on EKG monitor showing NSR s ectopy. Pt had been given a 20ga IV in her R hand and was receiving an IV drip of 1000ml Normal Saline at 100ml/hr and an IVP drip of Levaquin via that IV site. RN std that Pt had also received an IV bolus of 40mg Lasix approx 20min prior to our arrival as well as 1000ml Tylenol PO for a recurrent fever, last measured at 101.5 degrees. Pt was on o2 at 4-LPM via NC bringing her SpO2 to 98%. Pt had a foley cath in place (thank goodness). Pt was unable to ambulate due to her condition and resultant weakness. Pt secured on cot and taken to rig. Vital signs assessed and per previous in this report (Yes, this is the ONE thing that the check boxes are good for). Pt denied CC other than of being tired. ASSESSMENT: As above. Skin Warm, pink, and moist. Pupils PERRL, no JVD, trachea M/M, Chest equal rise/fall bilaterally c diffuse rhonchi and rubs throughout. ABD SNT. Extrem c good Pulse/motor/sensation/temp x 4. Some pitting edema noted to both lower extremities. Pt was resting comfortably and std that she "felt much better" after the Tylenol. Pt denied other complaints. TREATMENT: All inpatients treatments continued. Pt maintained on o2. Pt maintained on EKG showing NSR s ectopy. Pt rested comfortably during transport without any additional complaints. VS (vital signs) q 15min without change observed. Pt transported and transferred to St. Bernard ICU RN staff s incident or exacerbation of condition.

The two reports above could not be much more different, however if you look, they are both written using the same, versatile format. SOAP is a tool for you to use to help organize your information and tell your story of the patient care. Use it as a guide, or a process. Don't use it as a strict format. It will help you as it has me.

Remember, the SOAP chart is just one example of the EMS narrative report, the EMS patient care report, the Paramedic narrative, the EMT narrative, the ambulance report, or the patient chart. Written well, and you are improving your patients' care. Write it poorly, and you're harming your patient and maybe looking like an idiot.

You may print this out and use it with my permission, as long as there's a link: Http://www.LifeUnderTheLights.com – and my e-mail: Proems1@yahoo.com

Till later, all.