ems patient care report reddit

What should be included in an EMS report?

History of presenting illness/injury (what were the circumstances that caused EMS to be activated) Physical Exam ( system by system exam of the relevant systems, or details of a focused exam of a localized problem) Treatment/transfer (what we did on scene, en route, and who we took them to.

What is/R/EMS?

/r/EMS is a subreddit for medical first responders to hangout and discuss anything related to emergency medical services. Reddit Inc © 2022 . All rights reserved

What are some tips for writing a medical report?

Miscellaneous (any extra info that needs to be noted... for example the cause of a scene delay on a major trauma or something like that) I like to emphasize proper spelling, grammar, and medical terminology. Break up the wall of text with paragraphs for each 'section', and avoid using short forms or abbreviations.

How do I write a patient care report in EMS?

EMS providers just need to pull the information together and write it down in a way that paints a picture....Follow these 7 Elements to Paint a Complete PCR PictureDispatch & Response Summary. ... Scene Summary. ... HPI/Physical Exam. ... Interventions. ... Status Change. ... Safety Summary. ... Disposition.

How do I write a prehospital care report?

The following five easy tips can help you write a better PCR:Be specific. ... Paint a picture of the call. ... Do not fall into checkbox laziness. ... Complete the PCR as soon as possible after a call. ... Proofread, proofread, proofread.

How do you write an EMS narrative?

How to Write an Effective ePCR NarrativeBe concise but detailed. Be descriptive in explaining exactly what happened and include the decision-making process that led to the action. ... Present the facts in clear, objective language. ... Eliminate incorrect grammar and other avoidable mistakes. ... Be consistent and thorough.

What should a patient care report include?

What Patient Care Reports Should IncludePresenting medical condition and narrative.Past medical history.Current medications.Clinical signs and mechanism of injury.Presumptive diagnosis and treatments administered.Patient demographics.Dates and time stamps.Signatures of EMS personnel and patient.More items...•

What is a patient care report?

The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool. The documentation included on the PCR provides vital information, which is necessary for continued care at the hospital.

What is EMS documentation?

First and foremost, EMS documentation serves a vital clinical purpose. It is the record of your assessment and care of patients. It becomes part of the patient's medical record, both at the receiving facility and within your EMS organization.

What is a component of the narrative section of a patient care report?

The narrative section of the PCR needs to include the following information: Time of events. Assessment findings. emergency medical care provided. changes in the patient after treatment.

Which format should be used when writing the narrative section of a patient care report?

SOAP NOTE: Traditionally, the SOAP method is used for narrative documentation and includes all pertinent information. SOAP is an acronym for a patient care report that includes: Subjective: details relative to the patient's experience of the illness or injury like onset time, history, complaint, etc.

What byproduct of being in EMS caused you to act “abnormally” to others?

Here’s what I did. At a college campus a friend of a friend was saying she was in a “fuck ton of pain and may need to go to the hospital”. A bunch of her girlfriends were giving her attention as a result. Because of my experience in EMS, I saw straight through her bullshit: she was not in much pain if at all and pretty much just wanted attention at the social gathering. I questioned where she was feeling pain and she couldn’t give a straight answer and she kind of snapped at me and her friends frowned at me too.

Why do physician reports sound good?

The reason a lot of physician reports sound good is because they dictate and then it's transcribed, or they have dedicated time for charting. ED physician reports don't sound like that unless the patient is being admitted. The reports on the pts being discharged from the ED to home read more like our reports.

What format do you follow on 911 calls?

On the 911 calls, I follow SAMPLE & OPQRST while writing down info on paper. When doing the narrative in the ePCR (or IFT stuff), I follow the CHART format, with SAMPLE/OPQRST listed under A. Helps insure that I don't miss anything.

What is the difference between doctors' reports and ours?

A big difference I've noticed between doctors' reports and ours is theirs always sound more personal and professional. Ours always sound robotic and strange. This is usually encouraged in school, for objectivity, but I like to gussy up forms a little.

Why do you want to make it clear what condition the patient was in when you transferred care?

You want to make it clear what condition the patient was in when you transferred care because that means less risk of someone coming back two years later to sue you for something that wasn't your fault. And most of all, this all applies hardest to patient refusals. Patient refusals are what will screw you. 5.

Can you learn a lot from doctors' reports?

You can learn a lot about reports if you go through doctors' reports to one another for their patients. This is something you'll only see on certain interfacility transfers, but have a look next time the nurse hands you that big stack of papers for that patient going to a different hospital.

What does epi do to dead people?

All epi in dead people does is keep earthworms up at night!

Why is it so hard to use a template?

It's kind of hard to use a "template" that is already prewritten for calls because you'll either leave out or a lot or end out having to add a lot. The problem is that patient's don't typically have just one symptom, and sometimes you have to go in a bit further for each one (it's not always as simple as OPQRST only).

Is eliciting a patient history a mystery?

Eliciting a patient history is not llike trying to solve a mystery.

Can you use a template for ALS?

I agree with DesertMedic66 asides from the we responded part to the narrative, a template isn't very useful for ALS calls. The only time I've ever used a template is on dialysis calls and even then I was still writing them.

Paper Patient Care Report (PCR)

Here is an example of two versions of print out, paper PCR you can download and use in your service.

Electronic Patient Care Report (ePCR)

The state of Alaska provids a free ePCR (Electronic Patient Care Report) system allowing communities to customize their run report forms to match their specific community needs.