One of the most preferred formats to use when writing a narrative patient care report report is the C-H-A-R-T method. When following this method, it is much easier to word things so that it; number one covers your butt, number two, it helps the staff at the ER to be able to find really quickly what your call was for, how they were when you found them, what you did for them, what drugs were given and anything else in a simple dummy-proof format. Also, depending on how you word your PPCR will make the difference in your agency getting paid for the call or not. If they don’t get insurance payment for the transport then eventually you won’t have a job there!
“C” stands for chief complaint. What is the patient’s chief complaint? If they say “I feel weak”, then you write, C- “I feel weak.” It is in the patient’s own words what is wrong with them to cause them to call 911. “H” stands for history of present illness. this is not the place to list every single medical problem they have ever had, this is where you document what the patient tells you such as; if it is a chest pain call, H- Patient stated that she started experiencing chest pain approximately three hours ago, after three Nitro, she felt no relief and called 911. You can even elaborate on if the chest pain was radiating or what was going on with the chest pain.
“A” stands for assessment. An example would be; ‘Upon our arrival we found a 33 year old female patient supine experiencing difficulty breathing and chest pain. Upon assessment, patient stated that at that time chest pain was 5/10. Breath sounds, clear bilateral, vitals assessed and noted. Skin: diaphoretic, pale. Patient was placed in 15 lpm O2 via NRB mask, placed on stretcher and placed in the truck. Continued to assess patient enroute with improvement noted.’ Note everything you observed with your patient.
“R” stands for Rx, or treatment rendered. R- Patient was placed on 15 lpm of O2 via NRB mask, 0.4mg of NTG given every five minutes totaling three per protocol, rechecking vitals prior to each administration. Patient was transport in position of comfort. Do not leave out anything you did in this section. If they had a reaction, say they had a reaction and what you did for that reaction.
“T” stands for transport. Where did you transport your patient? So many people leave this out. It’s so important to say where you transported your patient, who you turned your patient over to, and that report was given. Example; T- Patient was transported to (name of hospital) ER, placed in room 2, report was give to Jane Doe, RN, without incident. If there was an incident such as your patient bumped her head while transferring from your stretcher to the ER stretcher, note it here and that you made the staff aware of this incident.
It may seem like a lot to write, but you absolutely do not want to get sued and end up loosing your career and everything you own because you documented something wrong. It happens a lot more than people realize. So even if it takes more time, make sure you write a good patient care report.