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PCR: Heart Block

This is an example PCR narrative using the Pre-SOAPeD format. Read about Pre-SOAPeD and EMS Documentation here.

PRE-ARRIVAL:
Unit 292 responded emergent from headquarters for a reported Unconscious / Unresponsive at 123 Hogwartz Lane in the city of Outer Space with a full crew and without delay.

SUBJECTIVE:
On arrival, found a 64 year Male patient weighing 136 KG. Chief complaint of Unresponsive.

-History of Present Illness-
Wife at scene states she heard a loud bang and found her husband on the ground verbally responsive. She states patient had felt agitated earlier today but had no other complaints before incident.

-Histories-
Medical/Surgical History: Diabetes Type II, EMP / Emphysema, PNA – Pneumonia, Sleep Apnea, Coronary Artery Disease, Hypertension / HTN, Smoking Tobacco, CAT – Cataract, CABG / STENT / Bypass Graft, Personal history of antineoplastic chemotherapy, Cholecystitis.
Environmental Allergies: Bee venom allergy. Medication Allergies: Augmentin.
Current Medications: metoprolol succinate, Fenofibrate, irbesartan, Isosorbide, Lasix, Humalog, Levemir, Lyrica, NITRO Nitroglycerin, Omeprazole, oxcarbazepine, Pristiq, Vitamin D, Vitamin E.

OBJECTIVE:

-Initial Exam-
At 14:41, the patient was found. Initial assessment revealed the patient physically responsive and only able to make eye contact. Airway Patent, Lung sounds clear but diminished bilaterally, breathing pattern regular. Skin pale, cool diaphoretic, pulses weak, slow and irregular. GCS of 8 (Eye = 3, Verbal = 1, Motor= 4), Initial Vital signs, P – 32 II, R – 10.

-Secondary Exam-
Head to toe exam of patient revealed pupils regular round and reactive, HEENT CLR, negative jugular vein distention or tracheal deviation, abdomen distended non-rigid in all four quadrants, negative signs of trauma. Positive urinary incontinence noted.

-Lab Values-
Blood Glucose: 203; 3-Lead EKG showed complete heart block 30s-40s. SPO2 Initial 80% Room Air.

ASSESSMENT:
The field impression of the patient was [Cardiovascular] Cardiac Arrhythmia/Dysrhythmia.

PLAN:
Treatments were administered as follows:
14:42: Patient Assessment was performed successfully after 1 attempt.
14:42: Blood Glucose was performed successfully after 1 attempt.
14:43: Airway Opened was performed successfully after 1 attempt.
14:44: Oxygen 15 Liters Per Minute (LPM [gas]) NRB/PRB per Protocol (Standing Order). The patient’s response was Improved.
14:47: 3 Lead ECG Obtained was performed successfully after 1 attempt.
14:47: Pacing (External) was performed successfully after 1 attempt.
15:00: Medical Control Contacted was performed successfully after 1 attempt.
15:15: CPR – Manual was performed successfully after 1 attempt.
15:15: Bagged Ventilations (via Mask) was performed successfully after 1 attempt.
The patient was transported to Our Lady Of Holy Crap Hospital Emergent (Immediate Response).

-DELTA and HANDOFF-
Patient moved on stretcher, O2 administered, patient maintained airway and respiration on his own. Patient showed improvement with trans-cutaneous pacing (rate 60 bpm and 110 mA with mechanical capture) and was able to answer questions. Notification made to Medical Control resuscitation team requested.

Upon arrival at ED patient was moved to Cardiac Bed 1. Full report given to staff and in-hospital resuscitation begun immediately. EMS provider stayed and assisted transfer of pacing to hospital device when pulses were lost and CPR began in resuscitation bay. ROSC achieved shortly after and ED physician placed transvenous pacing device. Patient left in bed, with rails up, bed locked in staff presence.

Cite this article as: Scott Kostolni, EMT-P, "PCR: Heart Block," from SickPatient.com, November 3, 2017, date accessed: July 20, 2018 http://sickpatient.com/pcr-heart-block/

PCR: Penumonia

This is an example PCR narrative using the Pre-SOAPeD format. Read about Pre-SOAPeD and EMS Documentation here.

 

PRE-ARRIVAL:
Unit 292 responded emergent from headquarters with full crew and without delay for a reported Breathing Problem / Respiratory at 123 Hogwartz Lane in the city of Outer Space.

SUBJECTIVE:
-HPI-
On arrival, found a 61 year Male with a chief complaint of “I’m having trouble breathing,” as stated by patient. Secondary complaint(s) of Vomiting, Fever and Weakness.
Patient stated he awoke with above complaints this morning but recalled feeling normal last night before bed. Complaints worsened with movement, and patient felt best while lying in his bed. Patient describes respiratory distress as an inability to catch his breath and states he feels exactly like he has in the past when he’s contracted aspiration pneumonia. Patient had not tried any interventions before calling 911.

-Histories-
The patient’s medical history, medications and allergies are noted below.

-Review Of Systems-
GENERAL-Fever, chills, weakness;
RESPIRATORY-shortness of breath, dyspnea on exertion;
GU/GI-Vomiting, Nausea;

OBJECTIVE:
-Primary Exam-
Patient alert and oriented to person, place, time and event, airway patent lung sounds clear and equal bilaterally with the exception of ronchi in the upper left and even chest expansion, respiratory pattern rapid and labored, skin pale with positive signs of distal circulation. GCS of 15 (Eye = 4, Verbal = 5, Motor= 6).

-Secondary Exam-
Exam revealed pupils equal and reactive, abdomen soft, non-tender, non-distended in all four quadrants. Exam otherwise unremarkable.

-Lab Values-
Initial V/S of 172/80, P – 122 RR, R – 24. Initial SPO2 87% on Room Air. EKG showed Sinus Tachycardia 110-130s negative for STEMI.

ASSESSMENT:
The field impression of the patient was Pneumonia, unspecified.

PLAN:
Treatments were administered as follows:
07:15: Patient Assessment was performed successfully after 1 attempt.
07:17: Oxygen 12 Liters Per Minute (LPM [gas]) NRB/PRB per Protocol (Standing Order). The patient’s response was Improved.
07:31: 3 Lead ECG Obtained was performed successfully after 1 attempt.
07:33: 12-Lead ECG. Interpretation was Sinus Tachycardia 110-130, does not meet STEMI criteria. Lead: I, III, II, V1, V2, V3, V4, V5, V6, AVF, AVL, AVR.
07:33: 12 Lead ECG Obtained was performed successfully after 1 attempt.
07:35: IV Access – Extremity Vein20 gauge, was performed successfully after 1 attempt.
07:37: Ondansetron 4 Milligrams (mg) Intravenous (IV) per Protocol (Standing Order).
The patient’s response was Improved. The patient was transported to Our Lady of Holy Crap Hospital Non-Emergent.

DELTA:
Patients SPO2 rose to 96% and then 100% on NRB, respiration rate returned to normal and patient vocalized relief. Nausea subdued after ondansetron. IV lost en route removed and bandaged before arrival at ED.

-Hand Off-
Full report given to staff upon arrival. Patient transferred to bed 6 via pull sheet, left with bed locked, rails up in staff presence with all therapies continued.

Cite this article as: Scott Kostolni, EMT-P, "PCR: Penumonia," from SickPatient.com, November 3, 2017, date accessed: July 20, 2018 http://sickpatient.com/pcr-pneumonia/

Pre-SOAPeD Documentation

Importance of Documentation


  • Documentation is an important and often neglected part of patient care. Strong documentation protects both the patient and the EMS provider.
  • Documentation should be thorough and paint a complete picture of the patient, their emergency and the care provided.
  • The more information you can give to the physicians at the hospital the more time you save for your patient and the better care they receive.
  • Poor documentation has been associated with increased mortality in certain patients.
  • Goal: To write thorough enough documentation to prevent the need for in-person deposition for litigation.

Documentation Formats


  • There is different formats for documentation including CHART, Timeline Narrative, SBAR, and SOAP.
  • The Pre-SOAPeD format created by Joe Paczkowski on his blog EMT-Medical Student has become my preferred method for documentation.
  • It is thorough, straightforward and helps bridge the gap between pre-hospital care reports and the in-hospital charts and progress notes.

Pre-SOAPeD Reporting Checklist


  • Pre-arrival
    • Ambulance Unit Number
    • Emergent/Non-Emergent Response
    • Call Type
    • Location
    • Crew type
    • Delays
  • Subjective
    • Chief Complaint
      • Age/Sex of patient
      • Position of the patient when found.
    • History of Present Illness
      • Signs and Symptom
      • Onset, Provocation/Palliation, Quality, Radiation, Severity, Time, Interventions
    • Allergies/Medications
    • Medical/Surgical History
    • Family/Social History
    • Review of systems (As Applicable)
      • General
      • Neurological
      • Psychological
      • Head, Ears, Eyes, Nose, Throat (HEENT)
      • Cardiovascular
      • Respiratory
      • Abdomen
      • Gastrointestinal/Genitourinary
      • Musculoskeletal
      • Hair, Skin, Nails
  • Objective
    • Initial Assessment
      • Initial Vital Signs
      • Mental Status
      • Airway, Breathing, Circulation
    • Secondary Assessment (Body System As Applicable)
      • General
      • Neurological
      • HEENT
      • Cardiovascular
      • Respiratory
      • Gastrointestinal/Genitourinary
      • Musculoskeletal
      • Hair, Skin, Nails
      • Lab Values (SpO2, EKG, BGL, etc)
  • Assessment
    • Primary Impression
    • Additional items of your differential that you cannot rule out.
  • Plan
    • Treatments, interventions, dosages, equipment sizes
  • Delta (“change,” or response to treatment) and Hand-Off
    • Patient’s response to treatments
    • Vital Changes
    • Reassessments
    • Transfer of care
      • Nurses name
      • Bed patient moved to
      • Status of patient at transfer

See: Pre-SOAPeD Examples

Review of Systems


  • An inventory of the body systems obtained by identifying the absence or presence of various signs and symptoms.
  • With a problem-focused assessment, the review of systems should be related to the chief complaint and EMS Provider’s primary impression.

Review Of Systems Checklist

General: Fever, Chills, Malaise, Fatigue, Night Sweats, Weight Changes
Neuro: Seizures, Syncope, Loss of Sensation, Weakness, Paralysis, Loss of Coordination, Memory Issues, Muscle Twitches, Signs of Stroke
Psychological: Depression, Mood Changes, Difficulty Concentrating, Anxiety, Irritability, Sleep Disturbances, Fatigue During the Day, Suicidal and Homicidal Thoughts
HEENT: Headache, Dizziness, Loss of Consciousness, Blurred Vision, Light Sensitivity, Double Vision, Halo or Auras, Changes to Sense of Smell, Epistaxis, Postnasal Drip, Sinus Pain, Sore Throat, Bleeding, Dental Issues, Ulcers, Changes to Sense of Taste
Cardiovascular: Chest Pain, Edema, Palpitations, Tachycardia, Arrhythmias, Hypertension, Cardiac Medications,
Respiratory: Shortness of Breath, Wheezing, Dyspnea, Orthopnea, Cough, Sputum Production, Hemoptysis, Bronchitis, Tuberculosis, Pneumonia, Asthma, Respiratory Infections
GI/GU: Appetite, Heartburn, Nausea, Vomiting, Diarrhea, Constipation, Hematemesis, Changes in Stool. Flatulance, Jaundice, Dysuria, Increase Frequency or Urgency of Urination, Hematuria, Flank or Suprapubic Pain, Erectile Dysfunction, Fluid Discharge, Testicular Pain, Menstrual Regularity, Last Menstrual Period, Dysmemorrhea, Vaginal Discharge, Abnormal Bleeding, Pregnancies, Contraception Use.
Hair, Skin, Nails:
Rash, Itching, Hives, Sweating, Bruising, Bleeding. Changes to Hair Color, Texture, Abnormal Loss or Growth. Changes to Nail Color, Brittleness, Texture.

Cite this article as: Scott Kostolni, EMT-P, "Pre-SOAPeD Documentation," from SickPatient.com, November 2, 2017, date accessed: July 20, 2018 http://sickpatient.com/documentation/

Resources and References


  1. Featured Imaged by NEC Corporation of American under Creative Commons License.
  2. Dana J. Laudermilch, Melissa A. Schaffer, Avery B. Nathens, Matthew R. Rosegart, Lack of Emergency Medical Services Documentation Is Associated with Poor Patient Outcomes: A Validation of Audit Filters for Prehospital Trauma Care, In Journal of the American College of Surgeons, Volume 210, Issue 2, 2010, Pages 220-227, ISSN 1072-7515, https://doi.org/10.1016/j.jamcollsurg.2009.10.008. (http://www.sciencedirect.com/science/article/pic/s1072751509014902)
  3. Mulvehill, S., Schneider, G., Cullen, C. M., Roaten, S., Foster, B., & Porter, A. (2005). Template-guided versus undirected written medical documentation: a prospective, randomized trial in a family medicine residency clinic. The Journal of the American Board of Family Practice 18, no. 6 (2005): 464-469
  4. Paczkowski, J. (2011, January 20). EMS Documentation: Introducing Pre-SOAPeD. Retrieved November 2, 2017, from https://emtmedicalstudent.wordpress.com/2011/01/20/ems-documentation-introducing-pre-soaped/
  5. LeBlond, R.F., DeGowin, R. L., & Brown, D. D. (2009) Degowin’s diagnostic examination (9th ed.). New York: McGraw-Hill Medical.
  6. www.cms.gov. (December 2010). Evaluation and Management Services Guide. Updated August 2017. Accessed November 2, 2017, from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf