Narratives

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.