EMS reports come in various flavors these days. When I first started in this game back when I was a young, idealistic EMT-Basic (as opposed to a still young idealistic paramedic) all we had were these gosh-awful paper reports. We called them "bubble sheets" and if you've grown up as an Illinois EMT you've probably seen your share of them. Illinois bubble sheets were these multiple carbon copy monstrocities that included two pages just chock full of fun. You had to fill them out for everything the state thought was important, making sure that all of the bubbles were colored in exactly right or the state would kick it back to you however later it was they actually fed it through the machine. It was like taking a test every time you had a patient contact. Nobody read the bubbles but the machine. So if you actually wanted to communicate useful information about the patient to future caregivers or if you wanted to remember details about the call for whatever reason afterwards, the State saw fit to give you a really small box with really small lines for you to write a narrative report.
I hate those things. Notice that the previous isn't a past-tense statement. Some EMS services in the State of Illinois still use those awful things for EMS reporting. Really. Ambulances in Illinois are still required to carry at least ten of them in every ambulance per Illinois Department of Public Health (IDPH) regulations. Honestly, I threatened to go back to using them when one of my services switched to a new EMS reporting software that I'm not sure I like. Let me just say that .html databases are not useful for large data collection projects. They're clunky, prone to losing data, and aren't user friendly.
Here is a little bit of information on data. I am a database specialist of sorts. In one of my positions I work in data management and control. I take huge volumes of aggregate data collected from disparate data sources, mash it together, break it into single data pieces, numbers, and "Yes/No" answers, and then ask questions of it to get back useful reports. I'm not a database genius like some (and real database pros may disagree) but the way that I understand data processing is that data can be computed when it is processed into "Yes" and "No" answers and/or numbers. "Yes" answers are "+1" and "no" answers are "-1" or "0" depending on the question. When data is broken down into these Yes/No questions, it can be processed through a mathematical formula to obtain clear, actionable results. That's why you see categories of data, lots of radio buttons and check boxes, and prewritten answers in the new reporting software that has to be NEMESIS compliant.
(In a later post, I'll analyze data harvesting, structuring, composition, computation, and reporting as it relates to EMS. And, if anyone needs the skills of a Data Ninja, I'm available for EMS data processing. Free for small projects)
Unfortunately for us humans, and especially us humans that work in an almost completely unpredictable and not-easily categorized environment, the type of information that we like to communicate with does not fit well into the structure needed by computers. Us humans communicate in ideas, in words, and in fluid conversational form where ideas are not rigid, and the same information can be quite different when read contextually.
Therefore, my favorite part of the EMS Patient care report or any patient chart is the narrative. If you've had the opportunity to read many patient charts, or even if you've flipped through the paperwork on patient transfers, the parts you probably gravitate to are the narratives. You probably also read the lab results. There's a reason for this. Humans like reading stories which are what narrative reports are. We also like quantifiable numbers, which are what the lab results are. These are pieces of information that we can wrap our brains around, sink out teeth into, and really understand. I would bet that there aren't many people out there who ever even read the canned data areas. I don't.
I write a stock EMS narrative report every time. Not word-for-word, but I follow the exact same formula and use different tools in my reporting as needed to fit the situation.
Here's an example of a patient that I'm completely making up off of the top of my head (really):
Ambulance 1 dispatched emergent through the 911 system for the 42yo F Pt (patient) for the chest pain. UOA (Upon our arrival) we were met by the Pt's family who directed us in to the patient. Found the Pt sitting upright in a chair CAOx3 c ABCs intact (Conscious, Alert, and Oriented with Airway, Breathing and Circulation). Pt c CC of substernal chest pain that she std (stated) began approximately 1hr prior to her calling 911. Pt described the pain as a "deep pressure" that she std began in the inferior sternal area and radiated to the L shoulder and into the L arm. Pt rated the pain at a "7" on a 10 scale and denied any provocative or palliative features. ALS ASSESSMENT (By: Ckemtp): (Note: Billing services want that last part) Skin pale, warm, and moist. Pupils PERRL, no JVD (Jugular Veinous Distention), Trachea Midline/Mobile, Chest Equal Rise/Fall Bilat c Clear Lung Sounds and as described above, ABD Soft/non-tender, Extrem (Extremities) c good PMS (Pulse/motor/sensastion) and Temp. TREATMENT: 12-lead EKG obtained showing NSR (Normal Sinus Rhythm) with occasional PVCs and ST Elevation noted in leads II, III, and aVF with machine and EMT-P interpretation of probable acute MI. o2 applied at 4-LPM via NC (nasal cannula). Pt secured on cot and taken to rig. IV established in R forearm running 1000ml warm NS TKO. Pt given 325mg ASA (Aspirin) PO and 0.4mg SL x 1 bringing her pain to a "5". STEMI alert called to St. Elsewhere with report given via MERCI (Medical Emergency Radio Channel – Illinois). Pt given 0.4mg NTG SL again bringing her pain to a "4" and again bringing her pain to a "3". Pt given 2mg MS04 (Morphine Sulphate) bringing her pain to a "2". Pt transported and transferred to St. Elsewhere ER RN staff s incident or exacerbation.
I've been writing that same report for years with each patient. It's evolved a bit, but I can fit everything I need to fit into it. I would think that any further healthcare providers would be able to discern the patient presentation from that report, and I would be able to recall the events of the call in the event that I had to. When I first started writing narratives, I was told to use tools like "SOAP", "CHART", and other acronymns. I hated them, because I felt overly confined by their rigidity. I decided that I would use the chronological narrative method, and I thought that I was using it for years… until I realized that my narratives reports are just SOAP charts with my spin to them.
"SOAP" is an acronym that stands for "Subjective, Objective, Assessment, and treatment Plan". As it goes, the "Subjective" information is the information regarding the call, the events that you found when you got there, and a bit of history regarding the subject of the report. The "Objective" information is the information that you found through objective observation of the subjective information. The "Assessment" is just that, and to signify it in the report I write "ASSESSMENT" in capital letters. In the assessment portion of my report, I include "pertinent negatives" or a full sentence regarding my secondary assessment findings. In this section, I put in the findings such as the skin condition, the lung sounds, and the abdominal condition. While the old adage is that if you didn't write it, you didn't do it. I say that 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. (G'head an
d read that last sentence again until it makes sense) Including the pertinent negatives in the report shows that you did a thorough secondary assessment which is helpful for defense in case there is a bad patient outcome. Finally, the treatment plan shows the treatment that you performed and the response that you got from that treatment. Be thorough. At the end of the report, I put in the stock information that I passed the patient to the facility staff after calling in a report.
A good EMS Narrative report does a few things. First and foremost, it presents information about the patient's condition and the care that they recieved. The information that EMS gathers is important to their further care. The observations we make and the assessments we take are a view of the patient when their illness or injury is most acute. Our information can set the stage for the entirety of the patient's care down the line. The EMS Narrative also serves to refresh our memory for when we get called in to the office for an unknown reason a year or so down the road. Remember, you're always writing the report for your own legal defense. I also like the narrative because since I write it the same every way and always try to make it as detailed as possible, I can catch when I didn't do as thorough of an assessment as I would have liked to.
The EMS narrative report is the best way we have to tell the story of our patient care. Make it good, make it detailed, and for goodness sake, use proper spelling, grammar, and punctuation. You will be judged by other healthcare professionals on the quality of your narratives, make them good and not only will you look good, but your patients will get better care.
I'd love to see some report styles used by different providers. So I'm asking y'all if in the comments section you would make up a narrative report and post it so that we all could see examples of other EMS Narrative reporting. I think that it'd be educational, and maybe if you're a geek like me… fun.
This post is part of a group of posts on EMS narrative reporting:
For more information, please read the following information on the EMS narrative report, SOAP charting, EMS Charting, and EMS Patient Care Reports.