I was jogged back into training mode the other day by a trainee (and a supervisor) when we were discussing narratives. While I feel that his presentation of a patient care report was a bit dramatic and over-reaching, I think it’s something that may need to be touched upon while the thought is in my head.
What exactly does the narrative do for us in a patient care report?
It is written that a narrative completes the permanent record of a patient contact.
My take is that it provides details about the contact that otherwise were not available in other parts of the report. It functions as an overall summary of the contact and findings noted in the report. When instructing trainees or students how to write narratives, I start with the two standard formats that I was taught as a young padawan.
The first was SOAP
I remember this format in a way that when I’m writing in this format it is always “what I’m told, what I see, what I examined and how, and what I did about it.” It’s not my favorite format mainly because a lot of times I gather history from places other than what the patient tells me because often the patient doesn’t even know their own history.
I prefer CHARxT
- Chief Complaint
- (Rx) Treatment
I like this method because it allows me to meld different sources of history into one concise location. It makes no sense to me, when you mention history as in SOAP, that you make multiple notes from where you got all the history from. Examples include one source of past medical history (PMH) from the family (whom I usually ignore unless they sound like they know what they’re talking about) and the medications you have on hand that belong to the patient what they are saying conflicts. The weakness of this format is that cardiac arrests usually fall under both Treatment and Transport, so it gets a bit confusing unless you combine to two.
Each contact you document, SHOULD have at minimum 4 components and at maximum 5.
Those 5 are:
- Patient Contact/Chief Complaint
- Disposition (Treat and Release or Transport)
Patient Contact/Chief Complaint
This is where you contact the patient and figure out why they (or someone else) called 911. If grand-daughter called 911 because grandma was snoring very loudly and wouldn’t wake up, her words should be placed in DIRECT QUOTES. If JuneBug called because his arm felt numb after sleeping on it, what he tells you should be in DIRECT QUOTES. Are you getting the feeling that what the patient tells you should be in direct quotes?
Why direct quotes?
It highlights the best reason why you were there (as legitimate or ridiculous as it sounds) in the patient’s own words.
Other information about initial delays to contact like access delays, unsafe scenes/staging, language barriers, patient belligerency, etc, should go in this section.
You should SUMMARIZE patient history in this section. 80% of your initial working diagnosis and that of the hospital is based upon how well you gather history. Putting notes in about grandma’s toe jam and recent ingrown toe nail surgery isn’t that significant unless you are talking about possibly sepsis or a problem with that area. It may be significant in diabetics, but if grandma is otherwise healthy, usually not significant. Use your clinical judgement.
This section will include all of your medical findings. I always include a head-to-toe summation of findings similar to what the transcriptionists use with hospital summary of findings but in a paragraph format. I also put information in here about invasive findings like blood glucose levels and a detailed interpretation of 12 lead ECG’s and monitor showings. If the initial blood pressure was anything but within a “normal range” and requires some sort of intervention, then I include some vital signs here, but that’s not a usual occurrence.
This is all the stuff you did. IV starts should include the bore size and location as well as number of attempts, and intubations are the same way and should include information regarding the number of passes required, capnography findings, depth at the teeth, and so on.
How you ended the call is just as important as everything else. If you released the patient (with or without treatment) then you should note mentation and other competency proving items. If you transported, then you should include how you got them onto your cot/stretcher/pram/whatever you call it and to the ambulance, what happened on the way to the hospital, and information about the hand-off like how you got them off your bed. Notes on the patient’s condition en route and at transfer of care should also go here.
These are guidelines, and you should always follow what your organization orders you to do, but it will usually fall back to a basic diagram like what I have shown.