jprleedy4680
Member
How do you personally organize your radioed patient status reports and written narratives? EMT student looking for tips on good report writing...
Thanks!
Thanks!
For the Medics/EMT's...
- Thread starter jprleedy4680
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jprleedy4680 said:How do you personally organize your radioed patient status reports and written narratives? EMT student looking for tips on good report writing...
Thanks!
For a radio report I keep it as simple as I can. I give age, sex, chief complaint, vitals, treatments, and ETA
For the written report I use the chart method. It's not the best but it helps my keep myself organized.
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NJEMT
Member
Radio- Age, sex, chief complaint, vitals, and then ETA
Narrative-I just write out the call ex. Upon Arrival EMS found pt where and in what position, complaining of this or that, vitals assesed, any thing done to the patient, how we moved them to the ambulance, any additional treatment: band-aids, o2, another set of vitals, and arrival at hospital.
Narrative-I just write out the call ex. Upon Arrival EMS found pt where and in what position, complaining of this or that, vitals assesed, any thing done to the patient, how we moved them to the ambulance, any additional treatment: band-aids, o2, another set of vitals, and arrival at hospital.
timlinson
New Member
Start with what Im dispatched for, location. Then go on to arrival, assessments, interventions, etc...
chfdbigbad said:
I-CHART Method
I- arrived to find (age, AVPU, position)
C- Chief complaint, and current history
H- Medical history, Medications
A- Allergies
R- Rx/ treatment, Physical Exam: Pertinent +'s or -'s
T- Transport
I start with demographics, then have a 2-3 paragraph scene description and subjective. I then have a premade checklist of the entire body with - bleeding, sensation, pain, etc... with room for narrative on each to describe. I then delve into treatment, followed by 2 paragraphs on patient transport and transfer.
For refusals I have all of this, except I replace transport with a 2-3 paragraph section stating what I explained to the pt, how they responded, etc...
All in all, the narrative part of my reports is usually 2 type written pages, out of a total of 7-9 pages which come from our software which allows me to input alot of the same info, but without narrative.
For refusals I have all of this, except I replace transport with a 2-3 paragraph section stating what I explained to the pt, how they responded, etc...
All in all, the narrative part of my reports is usually 2 type written pages, out of a total of 7-9 pages which come from our software which allows me to input alot of the same info, but without narrative.
Believe it or not, my instructor completely skipped over teaching us how to write reports. So when I started working on a rig, the medic tore me a new one on my complete lack of report-writing abilities. He taught me to give very basic info over the air(age, chief complaint, condition, and ETA), and in the report to just write a head-to-toe analysis of the patient. Works pretty well for me.
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For the radio reports, Pt demographics, chief complaint and brief appropriate hx if necessary, last vitals and any major pt changes during care, ETA.
jprleedy4680
Member
Radio reports will also differ for different systems and hospitals.
For example: Some places prefer to hear "vitals within normal limits" (assuming they are otherwise unremarkable) while other places want to know every number and value.
These nuances you'll have to learn when you start someplace new.
(I will add this: The radio report is for the purpose of triage, bed management and having resources ready when you arrive. Thus, PMH or Meds that aren't directly relevant to the emergency [like Coumadin in a stroke pt is relevant but gout medication isn't] should be omitted from the radio report. All the extra things can, and should, be conveyed when you give your report to the receiving facility staff in person.)
For example: Some places prefer to hear "vitals within normal limits" (assuming they are otherwise unremarkable) while other places want to know every number and value.
These nuances you'll have to learn when you start someplace new.
(I will add this: The radio report is for the purpose of triage, bed management and having resources ready when you arrive. Thus, PMH or Meds that aren't directly relevant to the emergency [like Coumadin in a stroke pt is relevant but gout medication isn't] should be omitted from the radio report. All the extra things can, and should, be conveyed when you give your report to the receiving facility staff in person.)
my PCR
who
what
when
were
and what i did for the pt
calling the hosp short and sweet
55 yo m shot pulse bp breathing quickly tell them what i or the medics did and eta
like this 25 yo m found shot pulse 40 weak thready bp 80 over 30 or 80 by palp resps 4 severe bleeding breathing being assisted eta 4 mins
who
what
when
were
and what i did for the pt
calling the hosp short and sweet
55 yo m shot pulse bp breathing quickly tell them what i or the medics did and eta
like this 25 yo m found shot pulse 40 weak thready bp 80 over 30 or 80 by palp resps 4 severe bleeding breathing being assisted eta 4 mins
Zack said:
+1 I give infomation that is directly relevant to the PT at that time. I dont give vitals unless it needs to be said other wise I say "vitals stable".
"This is Medic ___ coming in with 40 year old male with non traumatic back pain since last night, unknown cause. vitals stable. be there in 10."
theroofable
Member
theroofable
Member
ark_firefighter
Member
For Radio Report: Age, Sex, Chief Complaint, Vitals, Treatment (Basic Truck) ETA
We use EMSCharts.com and that pretty much lays it all out in the "action taken" section
We use EMSCharts.com and that pretty much lays it all out in the "action taken" section
bwoodruff
Member