I’m a maniac! A
maniac, I tell you! I fear no angry
comments! Let’s get some fights on this
blog!
Let’s talk about narratives!
Medics love their narrative patterns, and think that everyone
else’s are stupid. So I can take a
minute to explain my narratives and you can then tell me why they are
lame and ineffective. It's a fun EMS game!
The best way to hand-off patient information to other
caregivers, in my opinion, is in a conversational-style handoff report with time
for questions to be asked and answered. But we’re
busy and have to leave the patient’s side eventually, so we leave PCRs for the
hospital. In a PCR, the narrative holds
the best information, especially for follow on providers like physicians and
specialists who contact the patient after you have left the ED.
It seems like every EMS agency has a different PCR, with
different layouts and different information in different locations. Most providers look for the narrative – it is
pretty easy to find, and it will (hopefully) tell the whole story. I also prefer narratives to electronic, check
box-style documentation because I can type out a much better description almost
as quickly as I can check a box. Which
would you prefer: Head > Laceration;
or “Head: 3cm full thickness laceration superior to left eyebrow”?
Narratives are the best place to show off the good work that
you do. If you do good work, make sure
to show it off. If a medication or
procedure requires that certain conditions be met, make sure to point out those
conditions in your narrative. The
reverse is also true – I make sure to explain why I didn’t immobilize a
patient, or didn’t initiate care for a cardiac arrest.
I personally prefer the SOAP narrative format, which I
usually shorten further into SOP. But I
don’t think most people care if you write in CHART format or chronological
narratives. However you write a narrative, it is critical to ensure that communication
occurs. Make yourself clear. Make sure that your narrative is
an appropriate length. Excessively long
PCR narratives make finding important information more difficult. Excessively short narratives don’t contain
all of the pertinent information.
SOAP stands for subjective, objective, assessment,
plan. Subjective information is
information that you are told by someone else.
You can’t be held responsible for the veracity of subjective
information. In contrast, objective
information is data that you gained by your own actions. You saw it with your own eyes. People can tell me that their arm hurts
(subjective information), but I can see the flinching tenderness response when I
touch their arm (objective information).
The assessment section is the place for me to take a shot at what is going on
with the patient. I state what I was
working up the patient for, be it MI, abdominal pain, kidney stones,
whatever. Finally the plan section is a
list of the treatments that I performed in chronological order.
Personally, I don’t include information that is elsewhere in
the PCR unless it enhances the readability of the narrative. A lot of medics start their PCR narratives
with something like: “Medic 440 responded Code 3 for report of chest pain…” The unit, response mode, and dispatch nature
are already provided elsewhere in the PCR.
Why waste time with that?
With that in mind, my plan section is usually just a brief list of
treatments: “Exam, VS, IV, O2, transport without change or incident.” If someone wants the details of my IV, they
can look in the procedure section.
I use the SOP layout for medical, trauma, and cardiac arrest
calls, whether the patient was transported or not. The only difference is that some settings
(like cardiac arrests) shorten the subjective section. So my arrest narratives end up having really
short subjective (found down, no further information) and objective (grossly atraumatic) sections with
much longer plan sections. But I still
follow the same pattern.
So here is my base narrative. (The information between the < > signs
is to be filled in.)
Upon arrival, found
patient complaining of <complaint>.
<Explain the complaint – how long, PQRST stuff, etc.> Patient denies <include pertinent denials
such as chest pain, shortness of breath, nausea/vomiting, dizziness, etc.>
<Bystander statements, if they are pertinent>
Upon exam, patient
awake, alert, calm and cooperative in no apparent distress. Decision making
capacity: Intact; Skin warm/pink/dry.
Head: Atraumatic, PERL, Speech clear, No alcohol on breath; Neck: Supple
and nontender without JVD; Anterior/posterior chest: Atraumatic with equal
expansion, breath sounds clear to auscultation bilaterally; Abdomen: Soft and
nontender to palpation; Pelvis: Stable: Extremities x4: Atraumatic and
unremarkable. Sensation and movement intact and equal; SaO2: Whatever; ECG:
Whatever; EtCO2: Whatever; BG: Whatever
Upon exam <vehicle
description>
<Briefly list
treatments and other interventions>, Transport without change or incident.
If I don’t examine a pelvis, I delete the pelvis part. If I don’t look at the patient’s eyes, I
delete the PERL part. If there is no
vehicle involved, I delete the vehicle exam.
The finished subjective portion will read something like: “Upon
arrival, found patient complaining of 10/10 chest pain radiating to left
shoulder and jaw for 30 minutes. Onset
occurred while walking and patient describes pain as severe pressure
associated with mild shortness of breath and anxious feeling. Patient denies nausea/vomiting, abdominal
pain, attempted treatments prior to EMS arrival, recent trauma or illness,
alcohol or drug use, and previous similar episodes.” Make sense how that fits together?
Notice a few things.
First, I don’t use abbreviations very often nowadays. I have an electronic PCR system with my base
template saved on it. Some providers
save their base narrative on a flash drive – same thing. If it is saved, the abbreviations don’t save
me much time because I am not really typing the narrative. All I am doing is changing the “normal”
findings to whatever abnormalities I found.
Second, note the importance of pertinent negative findings. In addition, notice that it is all spelled correctly and is grammatically (generally) correct. Finally, notice
that I took the CAPS LOCK off. It is not
hard for me to briefly press the shift key with my pinkie finger when it is
appropriate.
Spelling and grammar are important. What do you think of the intelligence and
skill level of a medic who wrote something like this: “CALLED TO ADRESS ON A
ROLLOVER ON ARRIVAL WE AN FD ON SCENCE FD IS TRYING TO GET PT OUT OF CAR. NOTE:
PT CAR IS ON IT’S ROOF HEAVY DAMAJE TO CAR FRONT RIGHT AN LEFT SIDE AND REAR OF
CAR AND ROOF PUSHED DOWN ABOUT 1 FOOT PT LEGS IN DRIVERS SEAT AN DTOP HALF OF
PT IS IN BACK SEAT…”* It doesn’t reflect
well on the provider, does it? He or she
(face it, though, a narrative like that comes from a dude) may be a phenomenal
caregiver. But the impression gained
from the narrative is a negative one. Quit shouting a people with all-caps. Use a period once in a while. I
have read PCRs about “nife wounds to rists”.
Use the spell checker, or ask your partner how to spell knife.
Luk out! It's a nife! Watch yor rists! (Public domain via Wikimedia Commons) |
Narratives are a very personal thing to a medic, and they
don’t change a whole lot once the habits are set. Hopefully, though, there is an idea or two in
my narrative that you can steal and use in your future narratives.
*Invented narrative, but it is pretty close to other narratives I have had the pleasure of reading.