A guide to writing clear, concise EMS reports using SIREN

Transcription

1 A guide to writing clear, concise EMS reports using SIREN OBJECTIVE: EMS narratives will document patient assessment findings, interventions, and patient response to interventions such that ED providers may quickly and easily access this important information. In addition, accurate documentation will serve to harness the power of the electronic health record for data collection, statistical analysis, quality assurance & improvement, and service financials. METHOD: A systematic approach using section headers and spacing will allow for grouping of assessment information and visual clarity: CHIEF COMPLAINT HISTORY ASSESSMENT RESPONSE to INTERVENTIONS TRANSPORT/COMMUNICATION CHIEF COMPLAINT The CHIEF COMPLAINT section should introduce the incident with a short, concise sentence: CHIEF COMPLAINT: Chest pain CHIEF COMPLAINT: Right ankle pain HISTORY The HISTORY section should group subjective information, including the History of the Present Illness/Injury (HPI). Begin with a short, set the scene sentence: Found alert 76 y/o male sitting in recliner c/o chest pain. Found unresponsive 23 y/o male sitting driver seat of vehicle involved in MVC. Found alert 42 y/o female standing in living room of her apartment screaming, in care of law enforcement.

2 Continue with HPI. Try to answer two key questions: Why was the ambulance summoned? What events led to call for EMS? Examples of subjective information include: Description of the scene, as appropriate Nature of Illness: o Symptoms, using OPQRST Mechanism of injury: o MVC Speed & impact (frontal, side, rear) o Description of vehicle damage (spidering of windshield, intrusion) o Restraint or helmet use, airbag deployment o Reported loss of consciousness and recall of event o Reported head trauma Pertinent (subjective) negatives: o The patient denies pain in head, neck, and back. o The patient denies difficulty breathing and nausea. Allergies, medications, and pertinent past medical history should be documented using the Past Medical History drop-down menus in SIREN. List pertinent information in Narrative. o Overdose list meds taken in Narrative o Anaphylaxis list known allergens in Narrative o Chest Pain list past surgical history ( CABG x 2, 1/2012 ) in Narrative ASSESSMENT The ASSESSMENT section should group objective information, including the Primary Survey and Secondary Survey. A good physical exam is organized head to toe, and includes abnormal findings, as well as confirmation of normal assessment for pertinent (objective) negatives. Begin with detailed description of mental status: o AOx3, in acute respiratory distress, speaking in 1-2 word sentences o AOx3, NAD (no acute distress) and conversational o Responds to loud verbal stimulation by opening eyes but not speaking o Responds to painful stim by withdrawing Verify PRIMARY SURVEY: o Airway patent and self maintained o Airway opened with modified jaw thrust with relief of snoring respirations. Oral airway accepted. o Normal work of breathing. o Increased work of breathing as evidenced by tachypnea (RR 46), pursed lip breathing, tripod position, suprasternal retractions, and SpO2 84% on 2 lpm O2 via NC on arrival. o Breathing slow and shallow with SpO2 77% on arrival.

3 o Skin pink, warm, & dry. Strong radial pulse. Capillary refill time <2 seconds. o Skin pale, diaphoretic. Radial pulse rapid & weak. Continue with SECONDARY SURVEY by body region (examples below): o Head/Neck/Spine No tenderness with palpation to head, neck, or spine. Tenderness with palpation to lumbar region of spine. o Chest Equal chest expansion and bilateral chest rise. Breath sounds clear and equal. Diminished breath sounds right upper fields. Equal chest rise. o Abdomen Soft, non-tender. No guarding. Tenderness with palpation to RUQ & RLQ. o Extremities Moves all extremities. Extremities warm & with pulses present. o SpO 2 : Document lowest recorded SpO 2 level assessed. o EKG: Document 12-lead EKG acquisition and interpretation (or auto-interpretation) o FSBG: Document finger stick blood glucose (FSBG) level(s). o Enter all vital signs in Patient Vitals section of SIREN. Enter all abnormal physical assessment findings into Assessment Findings anatomical map or drop-down menu in SIREN. RESPONSE TO INTERVENTIONS The RESPONSE to INTERVENTIONS section should list all EMS interventions performed, and the patient response to the interventions. Enter interventions in SIREN, under Procedures/Treatments or Medications. Emotional support well received by patient. (this is the new PFA!) Oxygen administered with improvement in SpO 2 from 86% to 92%. The patient stated no improvement of dyspnea with oxygen. Albuterol 2.5 mg via neb administered. The patient stated much improvement of dyspnea; and re-assessment of breath sounds revealed less wheezes. Full spinal immobilization with equal neuromotor function in all extremities before and after immobilization.

4 TRANSPORT/COMMUNICATION The TRANSPORT/COMMUNICATION section should describe how the patient was transported and any assessment change en route. The patient was transported semifowlers on stretcher with less dyspnea en route. The patient was transported supine on stretcher with continued BVM ventilation en route. Document COMMUNICATION with Online Medical Direction anytime an EMS provider speaks to an ED Attending. The name of the ED Attending should be included. If an EMS provider is not certain of the name, this information can be obtained from the staff in the Communications Center at UVMMC after transfer of patient care. Other examples of documentation for this section include: UVMMC Comm Center advised of possible trauma alert from scene. UVMMC Comm Center advised of Stroke Alert from scene. 12-lead EKG transmitted to UVMMC Comm Center prior to departing scene. Automatic interpretation of, ACUTE MI communicated to via radio update en route. Cancelled call. Discussed with Dr. Wolfson/UVMMC ED. Critical calls in which there is limited HPI are sometimes better documented in a timeline format. Assessment and interventions can be grouped according to events that occurred on scene and en route. On scene, patient unresponsive to all forms of stimulation with blood in nose and mouth. En route, patient ventilated with high flow oxygen using BVM. SpO 2 improved and the patient became more combative. Please sign narrative: Written by John Doe, AEMT #12345 on 1/27/12 at 1018

5 CHIEF COMPLAINT: Chest pain HISTORY: Found alert 76 y/o male sitting in recliner c/o chest pain. Patient states onset of pain approximately 2 hours PTA while shoveling sidewalk. He describes the pain as pressure that has not been relieved with rest. The pain does not radiate. Nothing has made the pain worse, although the patient states he has been resting since the pain began. The patient states the pain is similar to the pain he felt when he had an MI in 3/2010. He rates the pain 9/10. The patient states he feels he cannot take in a deep breath. He denies nausea, vomiting, and dizziness. ASSESSMENT: AOX3 male, anxious, speaking in complete sentences. Skin pale, diaphoretic, & cool. Breath sounds clear & equal in all fields. Equal chest rise. No JVD. No pedal edema. Neuromotor function strong & equal in all extremities. RESPONSE TO INTERVENTIONS: Oxygen, 12-lead EKG, IV, ASA, NTG. No relief of chest pain or SOB with oxygen or NTG. TRANSPORT/COMMUNICATION: 12-lead EKG transmitted to FAHC. Comm Center notified of automatic interpretation ACUTE MI. Online medical direction received from Dr. Wolfson for NTG 0.4 mg sublingual and ASA 324 mg. Patient transported semi-fowlers on stretcher without change en route. Report to Dixie, RN Bed 11. Written by John Gage, EMT #12345 CHIEF COMPLAINT: Back pain HISTORY: Found alert 28 y/o female sitting in front seat of sedan c/o neck & back pain s/p MVC, in care of firefighters. Patient was the restrained passenger of a vehicle that was traveling at ~45 mph on snow covered interstate that slid off the road way, striking a tree on the passenger side front door. Moderate damage to passenger side of vehicle, without intrusion. Front and side airbags deployed. No spidering of windshield. Patient states she has full recall of the incident and denies loss of consciousness. She describes the pain as severe, and states it hurts to move her head or body. She denies pain anywhere else. The patient also denies difficulty breathing, chest pain, and dizziness. ASSESSMENT: AOX3, upset female. Breath sounds clear and equal in all fields. Equal chest expansion. Skin pink, warm, & dry with good pulses BUE. Pain with palpation to lower neck and thoracic spine. No deformity noted. No pain with palpation to lower back. Abdomen soft & nontender. Neuromotor function strong & equal in all extremities. RESPONSE TO INTERVENTIONS: Oxygen. Extrication using KED, with full spine immobilization via long board. Neuromotor function strong & equal in all extremities following backboarding. TRANSPORT/COMMUNICATIONS: Transported supine on stretcher with increased back pain en route. Report to Dixie, RN in Bed 32. Written by Roy DeSoto, EMT #12346