Posted: 8/3/2016 8:12:43 PM EDT
| I haven't done one in 16 years, I need to teach a bunch of kids and instead of trying to remember what I learned in EMT school, I need to find a powerpoint or something to go off of. TIA. |
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Narrative content for fire and ems. Quoted:
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Are you looking to write nfirs reports or are you trying to write EMS reports for the fire side? Narrative content for fire and ems. I would think your local EMS agency would have some guidelines to follow. The narrative space on our EMS forms was only about 1/8th of a page. We had an official 2nd page but I rarely used it. Mostly on runs where there was likely to have court testimony involvement like child abuse, suspicious DOA etc. Critical patients refusing aid and a couple times where cops were involved on ugly ways. For NFIRS I used a standard boiler plate type language to describe unit assignments, tactics, knockdown times and condition when we left the scene. I would think by now that most departments are using the EPCRS for ems calls now. http://www.ems1.com/ems-products/ePCR-Electronic-Patient-Care-Reporting/ |
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For EMS reports I use the following:
What we got called for, what we had when we got there, what we did, any resulting changes, any orders secondary to our report, changes enroute to ER and xfer. "Called to location for 56 y.o. F c/o SOB. UOA* met pt at front door c/o same. Pt to cot, to MICU. O2 sat @ 89%, O2 15 lpm/NRB w/increase to 95%. Obtained vitals & hx of asthma, monitor. Pt denied other c/o, stated onset of SOB appx 4 hrs ago, but she had no Albuterol. Contacted Resource ER w/info & hx, no orders. Xport ALS w/o incident, xfer ot ER #12 UOA @ RER." *Upon Our Arrival - a department accepted acronym in use for 20+ years. I use a similar format for fire reports, but a different, more detailed format when I'm constructing an investigation report. "While on regular duty assignment at Station X, at 1234 hours received notification by radio page of a possible fire at 1234 Main Street in our town. Responded with FF Schmedlap in Engine 1 to location, arriving at 1237 hours, where we observed a 2 story frame residence with heavy fire from the Alpha (North) and Delta (West) side windows. Was assigned by Incident Command (BC Putzenberg) to assume Operations, which I did. After interior crew reported fire under control at 1300 hours, I reported to IC, where I was assigned to investigations, with FF Boner assuming Operations. I retrieved the investigation materials from the BC vehicle and began my exterior survey at 1310 hours..." |
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Still have yet to run a day at my normal station, sorry for the delay. I am just going to type a quick ems template we use. Modified chart.
Basic response info. Which units and where we responded from if different from the station. PID: 63yof CC: chief complaint. PMH: Past med history. Meds: List of Meds Allergies: list of allergies. HPI: History of present illness. Patient was up last night feeling nauseated. She fell asleep at 21:00 feeling normal. Pt awoke at 08:00 this morning with weakness on the left side, and facial droop. She waited approximately a half hour before calling 911 hoping the symptoms would resolve. When they didn't she called 911. PE: Physical Exam. Pt was found A&Ox4 with a patent self maintained airway. Breathing was normal with CEBBS. Circulation was adequate with palpable peripheral pulses, warm dry skin and capillary refill less than two seconds. HEENT exam revealed no physical abnormalities. Cincinnati Stroke Scale was positive with left sided facial droop, slurred speach, and left rm drift, in addition pt was having balance issues and reduced field of vision in the periphery on the right side. Trachea was midline with no JVD noted. Chest wall intact with equal rise and fall. Abd was soft non tender. Pelvis was stable. Extremities were without abnormality. No neck or back pain. Pt was ambulatory with abnormal gait. Tx: Treatment. Pt was assessed. Vitals obtained. Pt assisted to the stretcher. Pt loaded into Medic unit. Pt placed on cardiac monitor. 18g IV in left AC saline lock. 12 lead ECG obtained. Pt transported in position of most comfort. Vitals monitored. Pt care transferred to the RN in room xx in the ED at xx hospital. RTx: Response to treatment. What changes happened good or bad. PCI: Provider's Clinical Impression. What you believed you were treating for. Probable stroke. Notes: Anything odd or out of the ordinary. Like needing to call adult protective services. Ambulance broke down etc. This is the format I use. ThingS change for trauma or some other things, but the format stays the same. Hope it helps. NFIRS reports is a pretty normal canned answer. Just paragraph form rundown of what happened. ETA: All info in that example were completely fictitious and do not represent any actual patient that I have treated. |
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With the advent of EPCR's a good portion of the narrative is not needed anymore. We have even had talks from management about programs that are all bubbled in anymore with NO narrative.
As it stands we have 2 approved formats. SOAP and CHART. I prefer chart as it is chronological and it fits better with how I do things. However the fire departments require SOAP Subjective - what they say Objective - what you see Assessment Plan or treatment Chief complaint or reason for response History of present complaint Assessment Rx treatment Transport and outcome. As stated above, don't forget pertinent negatives. Follow the NR assessment sheets. Hit all criteria. The electronic narratives have actually made my life easier as I have pre programmed templates in word that I put together for medical/trauma on my toughbook that I populate into the PCR and adjust as needed for each patient. My narratives are 100% consistent now and my time to write them has pretty much cut in half. |