It`s Time to Write a Theme

     In the classic holiday movie A Christmas Story, the entire class groans when the teacher assigns homework that involves writing. In much the same way, most EMS providers groan and can think of a hundred things more enjoyable than writing a run report.

     There is no state or National Registry skill station for writing run reports, yet it is one of the skills we use most often. Compare how many intubations you perform in one shift with how many run reports you write. Yet most EMS programs spend little time on the art of writing a run report, and many providers' ability to perform this skill is poor. Always remember that you are writing for two: you and the patient (care provided), you and the physician (transfer of care), the physician and patient (continuation of care), the billing service and patient (reimbursement), you and management (training and QI), and you and the courts (legal).

     Documentation Ground Rules

1. Spelling counts. If you have difficulty, carry a small medical dictionary or choose another word. We carry protocol and reference books to ensure we get it right—why not the same with writing?
2. Neatness also counts. If everyone on your crew can't read it, rewrite it!
3. Use correct abbreviations, or none. BS is blood sugar, bowel sounds and breath sounds (and something else entirely). Some services/hospitals have approved lists; get a copy. You might be surprised how many abbreviations are not real.
4. We hear, "If you didn't write it, it didn't happen." But the opposite is also true: "If you didn't write it, it doesn't mean it didn't happen." If you dropped the patient on a backboard and don't document it, it still occurred, and it will appear you lied about it.
5. Have a drink of water, take a breath and sit down in a quiet spot before you start writing.

     One of the ways I teach students to document a physical assessment is to follow the same pattern they learned to perform the assessment. In the adult patient, we perform a head-to-toe assessment, and this is a good basis to begin writing. The patient is complex and may have many or very few clinical findings; however, it's important to document both what we find wrong and what we don't. EMS providers are good at documenting bad findings, but not as good at documenting what is normal or unremarkable. This leaves the report reader wondering if something reported as normal was actually assessed at all.

     A method that is similar to charting in a hospital and is a comfortable format for medical providers of all levels to follow is referred to as a body-systems approach, which allows the EMS provider to think and focus on a smaller portion of the patient at a time, then assemble it into a larger patient picture. The pattern to follow is:

     GLOBAL: Indicates your general impression: neurological status (unconscious, confused, etc.), position of the patient (doubled over in pain, sitting, etc.), any obvious conditions (in a wheelchair, seizing, soaked with water, etc.), and overall skin color and condition (diaphoretic, dry, cold, etc.).

     HEENT: This stands for head, ears, eyes, nose and throat, as well as assessment of the mouth.

     Head: Is it intact? Are there deformities, swelling or lacerations?

     Ears: Presence of hearing aids, discharge, ability to hear.

     Eyes: Changes to color of sclera, PERRL or other condition (pinpoint, etc.). Indicate symmetry, any discharge or trauma.

     Mouth: Indicate whether teeth are intact; is there trauma to the tongue or lips? Note condition of tongue (dry, swollen, etc.), and obvious odors (alcohol, fruity, almonds, etc). Throat should indicate if JVD is present or that it is flat if normal. Is there tracheal deviation (and to which side?); indicate midline if normal. Is the c-spine tender or deformed?

     CHEST: Indicate if the chest wall is intact, has equal and full expansion, and if there is accessory muscle usage. Document breath sounds, as well as where you listened (back, chest, upper, lower, left, and right). Document any implanted devices (PICC line, MediPort, internal defibrillator or pacemaker).

     ABDOMEN: Include documentation of distention, tenderness, guarding, rigidity or masses.

     PELVIS: Indicate if intact or if there is incontinence.

     LOWER AND UPPER EXTREMITIES: Document if they are intact, or if there is deformity or swelling; normal range of motion; and presence of distal pulses, capillary refill and movement.

     POSTERIOR: Document if it is intact, as well as for deformity or tenderness to the spine.

     MACHINE FINDINGS: Document machine readings such as blood sugar, pulse oximetry, EKGs and capnography.

     There are many methods for documenting an assessment—no one writing style is perfect for every provider, but it must be complete, accurate and consistent. Documentation is used for statistics, billing and QI. Perhaps more important, it is used as a reference for continued ALS care in the hospital environment, providing legal and ethical treatment and assessment administered by the ALS provider.

ALS Documentation Reminders
     IV: Indicate gauge of catheter, site placed, type and amount of fluid administered and any complications. If unsuccessful, why, and how was it resolved (bandaged, elevated, etc.)?

     Intubation: Size of ET tube, depth inserted (e.g., 21cm at the teeth), confirmation methods used (at least two, one preferably being capnography)

     Medication administered: Dose, route (oral, IV, etc.), complications, reassessment of vitals. (Be particularly careful with medications like D50, which is in grams [g], and fentanyl, which is in micrograms [mcg].)

     EKG: Rhythm name, rate, any ectopy, lead monitored.

An Unremarkable Assessment
     GLOBAL: Sitting upright. Alert and oriented, verbal, skin pink and dry.

     HEENT: Head intact, no lacerations or deformity; ears have no discharge, no difficulty hearing conversation. Eyes are normal color, PERRL. Nose intact and symmetrical with no discharge. Mouth has no missing teeth, tongue pink and moist, no odors detected. Jugular veins are flat, trachea midline, and c-spine is non-tender with no deformity.

     CHEST: Intact, no crepitus, equal expansion, no accessory muscle use; breath sounds clear and equal bilaterally, anterior and posterior, upper and lower fields.

     ABDOMEN: Soft, non-tender, no masses or rigidity, no guarding.

     PELVIS: Intact, patient has no incontinence of urine or stool.

     LOWER EXTREMITIES: Bilaterally intact, no swelling or deformity, normal range of motion, distal pulses present, normal capillary refill, and normal motor function.

     UPPER EXTREMITIES: Bilaterally intact, no swelling or deformity, normal range of motion, distal pulses present, normal capillary refill, and normal motor function.

     POSTERIOR: Intact, no deformity or pain on palpation of spinal cord.

     MACHINE FINDINGS: EKG shows regular sinus rhythm at 76 with no ectopy; 12-lead EKG shows no abnormal findings; pulse oximetry 98% on room air; blood sugar 88 mg/dl.

Marc A. Minkler, NREMT-P, CCEMT-P, is a paramedic/firefighter with the Portland (ME) Fire Department and has been a student of EMS for over 19 years. Reach him at pfd225@roadrunner.com.