If you had to pick a methodology by which to document what you did on a given call, wouldn’t be best to actually document based on what you did?  Documentation by patient management gets its’ strength from your knowledge of patient assessment.  The better you know patient assessment, the better you can document the call.  In 1999, NHTSA introduced a new way of teaching patient assessment.  It was a world apart from the previous version.  The previous version of patient assessment that was taught in the United States was primarily designed for serious load and go patients.  Under the previous system, all patients were considered load and go.  The new version that came out in 1999 was more realistic and followed the ‘clinical pathway’ approach.  Patient assessment as it is taught today possesses the following key features:

• Every patient gets a scene size-up and a primary survey
• At the end of the primary survey the EMT or Paramedic chooses a follow up assessment.
• If the transport decision is ‘load and go’ then the while the patient is being packaged, the EMT or paramedic performs a ‘rapid trauma assessment’.  The rapid trauma assessment is a rapid assessment that and treats for specific life threatening conditions and is conducted from head to toe.  
• If the patient was not injured with a significant mechanism of injury and the patient is conscious, a focused history and physical exam is conducted while still on scene.  The focused history and physical exam consists of a medical interview, baseline vital signs, and an assessment of the patients’ chief complaint.
• All patients receive an ongoing physical examination while enroute to the hospital. 

Scene size-up/ assessment

The scene size-up is an overall assessment of the scene to which an EMT or Paramedic has been called to gain useful information that includes ensuring scene safety; determining whether a patient is suffering from trauma or a medical problem; determining the total number of patients and whether additional resources are needed to handle them.  First we make sure the scene is safe to approach the patient, if it is not safe, we do something to make it safe (like call PD, Fire Department).  Once the scene has been made safe, we figure out what caused the incident to occur in the first place (this is called the mechanism of injury).  The mechanism of injury will give us clues as to the severity and nature of the injury/illness (answers the question of do we bring a backboard and a c-collar or not).  Finally, we need to determine how many patients will need care.  The reason we look for this in the beginning is because the time to call for additional units is now and not later.  

To document the scene size up, you could write all four elements of the scene size-up like this:

Scene Size Up:  1 Patient, MOI – low speed MVC, no airbag deployment, does not meet Trauma Triage Criteria – Mechanism.

Notice nothing was said about scene safety.  The reader can infer (conclude) that by virtue of the fact that you were able to gather all of that information the scene was safe.  If something holds up your arrival to the patient, it should be explained in this part of your narrative:

Scene Size Up:  Severe traffic hazards found upon arrival, which required PD; approximately 6 minute delay in getting to the patient.  1 Patient, MOI – low speed MVC, no airbag deployment, does not meet Trauma Triage Criteria – Mechanism, 

Primary Survey

The primary survey is defined as the portion of patient assessment conducted immediately following scene size-up for the purpose of discovering and treating immediately life-threatening conditions.  The primary survey begins with EMT or Paramedic developing a general impression of the patient.  From this general impression, the medics will determine that the patient is or is not in cardiac arrest based on an absence of signs of circulation. If no signs of circulation are found, the medics should start CPR. Once CPR is initiated, further assessment is really not required as CPR works in cycles of 30 compressions and 2 ventilations only stopping to defibrillate (if necessary) and checking for a pulse every 4 minutes. If the mechanism requires immobilization, then the medics are to begin immediate stabilization of the c-spine (stabilization is different from immobilization in that stabilization is usually done manually and not with a splint (c-collar and backboard)).  Moving forward, we assess the patients’ level of consciousness using the AVPU scale.  Next we assess the airway.  If the patient is able to speak, we can usually assume the airway is clear.  If the patient does not speak, we open the airway with an appropriate technique (jaw thrust for trauma or otherwise head-tilt-chin-lift).  If the patient was unable to speak, we assess the patency of the airway be observing air movement, if no or inadequate air movement is found, we ventilate with a bag-valve-mask.  If, during our attempt to ventilate the breaths do not go in, we re-position the airway.  If re-positioning fails to allow a breath to pass through the airway, we assume the airway is obstructed and begin AHA BLS for HCP airway maneuvers.  If at this point you are not ventilating the patient, you should assess the patients’ respiratory status by determining rate, rhythm, and quality.  If required, begin ventilations or administer supplementary oxygen with a non-rebreather or nasal cannula.  After assessing respiratory status, we assess the patients’ pulses (comparing the distal pulses to central) and observe the patient to determine if there is any obvious and life threatening blood loss.  Finally, it is time for us to make a transport decision.  At this point, what we are deciding is do we transport now or later (this decision is based on mechanism of injury, level of consciousness, or other findings of the primary survey).  

To document the primary survey you could write the following:

The patient found sitting in the drivers’ seat and did not appear to be in distress and was conversing with police officers.  Immediate c-spine stabilization was performed.  The airway was open & clear.  Respirations were adequate (Rate – 22 Rhythm and Quality were normal), Circulation was adequate (no obvious bleeding with intact peripheral pulses).  Transport was deferred so that a focused history & physical examination could be performed.

The above was a way to document the call.  You could shorten the narrative with abbreviations so long as everybody knows what the abbreviations mean (your agency might have a list of commonly used abbreviations).  Also note that some vital signs were included in the narrative.  Many people feel that the information contained in the narrative should not include information found elsewhere on the report (like the vital signs section).   If you feel that duplicating some information is going to make your patient care report more readable, then go for it.  

Since this particular scenario clearly does not involve a critically injured patient, we shall proceed to the next appropriate assessment, the focused history and physical examination.  A focused history and physical examination can be performed on anybody who is 

1. Conscious
2. Not injured with a serious mechanism of injury

All kinds of patient’s fall into this category, many with life threatening conditions.  The critical patients are going to have some sort of medical condition that requires treatment.  The difference is that unlike trauma, medical patients usually aren’t laying in pool of their condition.  Meaning, the only way to assess and eventually resolve the patients’ problem is to ask them what is wrong.  Additionally, the window for treating conditions such as myocardial infarction and stroke are much wider than the golden hour.  That is the point of the focused history and physical exam.   The first thing that is done in a focused history and physical examination is to re-evaluate the mechanism of injury.  Follow-up questions are asked to further define the chief complaint in terms of onset, provocation, quality, radiation, severity, and time.  Next EMS will determine what (if any) allergies, medications, pertinent medical history, last meal (and when appropriate last menstrual period), and events the patient can advise us of.  Following the SAMPLE history, the EMS crew should take a set of baseline vital signs.   And then perform an assessment of the patients’ chief complaint (further referred to as the focused physical examination).   To sum up the focused physical examination in as few words as possible, basically assess the patients’ complaint.

To document the focused history and physical examination you could write the following:

Subjective:  The patient complains of right arm pain following a motor vehicle accident.  The patient advises that the pain was not there before the accident and describes the pain as an achy sensation that radiates up the arm to his right elbow.  The patient rates the pain as a 2 on a scale of 1 – 10.  The patient denies loss of consciousness, difficulty breathing, nausea/vomiting/diarrhea, chest pain, neck or back pain, inability to speak.  The patient advises that he was wearing his seatbelt and describes the accident, “…I was traveling at approximately 20 mph, when I was distracted by an attractive pedestrian… I wasn’t paying attention when I struck the car in front of me.” The patient states, “…It’s just my arm that hurts, do I really need to go to the hospital?”

Objective:  EMS dispatched to a motor vehicle collision at the intersection of a county road.  Upon arrival, EMS found the car, still in the intersection without significant damage.  Very little intrusion was found anywhere on the front of the vehicle.  Damage was confined to the front bumper.  The airbag was deployed. The patient found sitting in the drivers’ seat and did not appear to be in distress and was conversing with police officers.  Immediate c-spine stabilization was performed.  The airway was open & clear; Respirations were adequate; Circulation was adequate (no obvious bleeding with intact peripheral pulses).  Transport was deferred so that a focused history & physical examination could be performed.  The focused history and physical examination revealed pain without deformity to the right hand (which possibly was struck by the airbag).  The patient was able to move his right hand without pain and presented with good pulse motor sensory perception.  

Note that some of the things the patient says were included using quotation marks.  If the writer wants to paraphrase what a patient says in your words, you can that the patient ‘advised’ you of something (like in this case, he advised me that his hand pain was not there before the accident).  Also note that the description of the patients’ chief complaint did not have every component of OPQRST.  When writing a narrative, omitting certain details implies that those details were not present or an issue at the time of writing (this is why it is said, “if you didn’t write it down, it didn’t happen.”). 

Here is the finished narrative:

Subjective:  The patient complains of right arm pain following a motor vehicle accident.  The patient advises that the pain was not there before the accident and describes the pain as an achy sensation that radiates up the arm to his right elbow.  The patient rates the pain as a 2 on a scale of 1 – 10.  The patient denies loss of consciousness, difficulty breathing, nausea/vomiting/diarrhea, chest pain, neck or back pain, inability to speak.  The patient advises that he was wearing his seatbelt and describes the accident, “…I was traveling at approximately 20 mph, when I was distracted by an attractive pedestrian… I wasn’t paying attention when I struck the car in front of me.” The patient states, “…It’s just my arm that hurts, do I really need to go to the hospital?”

Objective:  EMS dispatched to a motor vehicle collision at the intersection of a county road.  Upon arrival, EMS found the car, still in the intersection without significant damage.  Very little intrusion was found anywhere on the front of the vehicle.  Damage was confined to the front bumper.  The airbag was deployed. The patient found sitting in the drivers’ seat and did not appear to be in distress and was conversing with police officers.  Immediate c-spine stabilization was performed.  The airway was open & clear; Respirations were adequate (Rate – 22 Rhythm and Quality were normal); Circulation was adequate (no obvious bleeding with intact peripheral pulses).  Transport was deferred so that a focused history & physical examination could be performed.  The focused history and physical examination revealed pain without deformity to the right hand (which possibly was struck by the airbag).  The patient was able to move his right hand without pain and presented with good pulse motor sensory perception.  

Assessment:  The patient possibly has a broken right hand

Plan:  Per protocol, the patient was immobilized on a long backboard and cervical collar.   The patient was given a cold pack for his hand and was transported to Some Hospital ER (who was notified while enroute).  While enroute, repeated ongoing physical examinations were performed (no changes recorded).

What if the writer want to document the results of a detailed physical examination or a rapid trauma assessment?  Easy, just list the body regions being evaluated and then write your findings in the spaces.

Head:  No crepitus or bleeding found, Pupils were equally reactive to light

Neck:  No JVD, trachea midline

Chest:  No penetrations or flail segment; bilateral equal clear breath sounds

Abdomen: Soft and non tender

Pelvis: Stable

Lower Extremities: No bleeding or deformities, PMS intact

Upper Extremities: No bleeding or deformities, PMS intact

Posterior: No penetrations, bleeding, or other trauma noted.