You must use D-CHART-I format in your narratives, regardless of if your current department uses a different narrative system.
D - Dispatch Information
What did dispatch tell you over the radio?
What mode are you being dispatched (i.e emergent or non-emergent)?
Did you respond lights and sirens?
C/C: Chief Complaint
What did the patient say is the problem? Use quotes if you can!
"My chest hurts."
"I can't feel my leg."
History (Hx):
Who is on scene when you arrive?
Patient's Family
Fire Department
Police Department, etc.
Who called EMS?
Patient
Bystander
Law enforcement, etc.
What is your general impression of the patient?
How did you find the patient?
Are they in distress? What body position are they in?
Were they walking around yelling?, etc.
Speak to the patient and ask them why they called EMS.
Many patients have a long list of medical history and chronic pain. They will say that they've been in pain for weeks or months, so as a provider, you need to know what is significant about TODAY! Why did they see it necessary to call EMS today if they've been living with pain for however long?
SAMPLE/OPQRST Questions
SAMPLE questions belong to the history section of your narrative.
OPQRST questions may be divided between the history and assessment sections, depending on how you like to tell the story. As long as it is accurate and makes sense, these deviations are acceptable.
Was any care rendered prior to EMS arrival?
Does the patient have any pertinent medical history/conditions? Does the patient take any medications?
If the answer is "No" to either, you still need to address that in your narrative.
Every trauma patient is a medical patient! You will treat them the same with your history - with additional attention paid to the mechanism of injury.
What was the trauma?
Ask about loss of consciousness, if they hit their head, etc.
A fall: Why did they fall? Ask if they fell from a chair, standing position, etc. Ask if they fell face first or if they fell on their back.
A car accident: Ask about seat belts worn, airbags deploying, and note any damage to the vehicle. Ask the patient's recollection of the accident, how fast they were going, and note who else was involved if anyone.
Assessment:
As a provider, you should ALWAYS do your own assessment and never take the word of another provider. If you are ultimately responsible for this patient, you take the hit if something happens to the patient because you failed to complete your own assessment.
AxOx? (person, place, time, and event)
GCS (eyes, verbal, motor)
Assess all life threats (Mr. 5) and mention each one.
Airway, Breathing, Pulse, Skin, External Bleeding (Ask about abnormal bleeding as well)
Do a complete physical assessment
Lung sounds, heart tones, palpating chest/abdomen (if indicated)
CMS/PMS and DCAP-BTLS for all traumas
Describe results from any test performed (stroke, concussion, etc.)
Initial and Secondary Vital signs (can also be included in the treatment section if preferred)
If a patient refuses a physical assessment, you still must complete a visual assessment and it needs to be documented that they refused a physical assessment!
Treatment (Rx):
What treatment did you administer to the patient? Include 5 rights!
Bandaging
Oxygen
Medication, etc.
Initial and Secondary Vital signs (if not already in the assessment section)
Did the patient's condition remain unchanged, improve, or worsen throughout transport?
Transport:
How did the patient move from their location to the stretcher?
Mention all stretcher straps applied.
What facility was the patient taken to?
How did the patient move from the stretcher to the hospital bed? What bed?
Mention all reports given, whether during transport or at the hospital, or both. Also, document who you handed off patient care to.
Mention obtained signatures.
If a patient denies transport, you need to explain to the patient your concerns for them if they choose not to go to the hospital. Then, they need to sign a refusal form and you need to document this happening. You should obtain a refusal signature and if they also refuse to sign that, you'll need to get a witness signature from law enforcement (any professional besides your partner if possible) of all their refusals.
Impression(s):
This is where you explain your differential diagnoses. What do you, as the provider, think is happening with this patient?
If someone calls for abdominal pain, your history and assessment should help you form your opinion of ectopic pregnancy, stomach ache, appendicitis, etc.
Note: Every scene has its own set of challenges. When in doubt, document exactly what you witnessed, what was said, and gain witness signatures from other first responders and your partner.
D: Medic 1 was dispatched to a Walmart parking lot for a traffic accident involving a prius vs. pedestrian. Medic 1 responded with lights and sirens.
C/C: "He jacked up my knee!"
Hx: EMS arrived on scene after the fire department. Upon arrival on scene, a firefighter informed EMS that they would handle the driver's refusal of medical care, but requested that EMS take over medical care for the bystander, as she wishes to be transported to the hospital. EMS went to assess the vehicle involved and noted that there was not any vehicle damage and the airbags did not deploy. No broken windows were noted and all lights were in tact. EMS noticed that the patient was sitting on the asphalt in the Walmart approximately 15 yards away from the prius that was involved in the accident. The patient was sitting up right hugging her right knee to her chest and crying. Upon introduction, EMS discovered that the patient is a 21-year-old female. The patient explained that about 10 minutes prior to EMS arrival, she was returning her cart to the cart station and the prius backed up abruptly, striking the outside of her right leg. She then describes being shoved to the ground but had to use her hurt leg to scoot away so she wasn't run over by the car. The patient denies any allergies to medications, medications taken, or medical history. The patient denies any interventions taken prior to EMS arrival.
Assessment: Patient is AxOx4 to person, place, time, and event with a GCS of 15. Patient has a patent airway and can speak to EMS in full sentences. Patient's breathing is adequate and lung sounds are clear and equal bilaterally. Heart tones are normal. Patient has bilateral radial pulses. Patient skin is pink, warm, and dry. No external bleeding noted by EMS. EMS checked the patient's C-Spine for DCAP-BTLS due to MOI and no abnormal findings were noted on the posterior. EMS noted that the patient's CSM is intact on right leg. EMS did not note abdominal rigidity on palpation. Abdominal sounds are normal in all four quadrants. Patient rates her pain a 10/10. The patient reports that the pain feels worse when she moves it at all from the position she's holding it in. EMS asked if her pain radiated anywhere else and the patient reported that she also had a sharp pain shooting to her hip. The patient is unable to straighten her leg without increased pain. When she tried, EMS noted shortening and flexion of her right leg and she could not return it to her original position. EMS checked her right leg for DCAP-BTLS and noted an obvious deformity to her right upper leg/hip region.
Rx: EMS administered Drug X to the patient via 18 g IV to the left AC. EMS initiated rapid transport of the patient in a position of comfort, head slightly raised and her right leg was padded with two pillows for support. Patient vital signs were monitored throughout transport. Initial vital signs on scene were: BP 150/86, PR 98, RR 18 unlabored, SPO2 98% on room air. Secondary vital signs upon arrival at destination were: BP 148/76, PR 92, RR 18 unlabored, SPO2 97% on room air. Patient condition remained stable and unchanged throughout transport, though her pain decreased within five minutes of treatment now rating a 7/10.
Transport: Patient was moved from ground to stretcher via extremity left x2. Patient was secured to stretcher with all appropriate straps and loaded into the ambulance. Patient was transported to Hospital ER without incident. Patient was moved from stretcher to Hospital ER bed 7 via draw sheet pull x3. Radio report was given to receiving facility during transport. Report was given to the receiving RN upon arrival. All required signatures obtained by EMS.
I: Possible hip fracture or fracture to high femur
Student Name EMTB
Texas EMS School
April 12, 2023
D: Medic 1 was dispatched to an apartment complex for a patient with abdominal pain. Medic 1 responded with lights and sirens.
C/C: "My stomach hurts so bad."
Hx: EMS arrived on scene at the same time as the fire department. EMS knocked on the patient's front door and the patient yelled for EMS to enter the apartment. EMS noticed that the patient was sitting on her couch in the fetal position, holding her stomach, and grimacing in pain. EMS notes a pile of vomit on the floor next to her. Upon introduction, EMS discovered that the patient is a 24 year old female. The patient explained that about 15 minutes prior to EMS arrival, she was doing a home workout and got a sudden sharp pain in her stomach. She then describes getting really nauseous, but not being able to get to the bathroom, so she fell onto the couch and vomitted. EMS asked if it was possible for the patient to be pregnant and the patient reported that it is possible as she is sexually active, but she recently started spotting so she does not believe she is pregnant. EMS asked if she had been late on her period in the last few months and the patient stated that she skipped the previous two months. Patient does not report any abnormal bowel movements. The patient denies any allergies to medications, medications taken, or medical history. The patient denies any interventions taken prior to EMS arrival.
Assessment: Patient is AxOx4 to person, place, time, and event with a GCS of 15. Patient has a patent airway and can speak to EMS in full sentences, though she would hesitate mid-sentence when experiencing pain. Patient has bilateral radial pulses. Patient skin is pale and diaphoretic. No external bleeding noted by EMS. Patient's breathing is adequate and lung sounds are clear and equal bilaterally. Heart tones are normal. EMS did not note any abdominal distention during visual assessment and did not note abdominal rigidity on palpation. The patient felt pain on palpation in right lower quadrant. Patient rates her pain a 10/10. Abdominal sounds are normal in all four quadrants. The patient reports that the pain feels better when she applies pressure to her lower stomach. EMS asked if her pain radiated anywhere else and the patient reported that she also had a cramping sensation"down there", which EMS clarified verbally that the patient was indicating her genital region.
Rx: No treatment provided by EMS. EMS initiated rapid transport of the patient. Patient vital signs were monitored throughout transport. Initial vital signs on scene were: BP 150/86, PR 98, RR 18 unlabored, SPO2 98% on room air. Secondary vital signs upon arrival at destination were: BP 148/76, PR 92, RR 18 unlabored, SPO2 97% on room air. Patient condition remained stable and unchanged throughout transport.
Transport: Patient was ambulatory with assistance from couch to stretcher. Patient was secured to stretcher with all appropriate straps and loaded into the ambulance. Patient was transported to Hospital ER without incident in left lateral recumbent position, as per patient request. Patient was moved from stretcher to Hospital ER bed 7 via draw sheet pull x3. Radio report was given to receiving facility during transport. Report was given to the receiving RN upon arrival. All required signatures obtained by EMS.
I: Abdominal pain, pregnancy possible
Student Name EMTB
Texas EMS School
April 12, 2023
Disclaimers: Everyone writes PCRs a little differently. As long as your information is placed in a manner that makes sense and you obtained all pertinent information, that is acceptable. PCRs should tell a story. If your PCR is subpoenaed one day, you should be able to remember that patient based on your report. If it isn't documented, it did not happen.
Additionally, please ensue that you follow the directions in your clinical orientation video and after each clinical/field experience, you obtain a preceptor sign off, have them complete all required evaluations, and you, as the student, complete your required evaluations.
Medic 1 was dispatched to a call for a patient with abdominal pain. Medic responded with lights and sirens until EMS was cancelled by dispatch PTA.
Student Name EMTB
Texas EMS School
May 22, 2023
D: Medic 1 was dispatched to an apartment complex for an assault. Medic 1 responded with lights and sirens, but staged for law enforcement until given the approval to arrive on scene.
C/C: "Nothing happened. I just fell into the mirror by accident."
Hx: EMS staged two blocks away from the scene until law enforcement was able to take control of the scene and allowed EMS to arrive on scene. EMS arrived on scene at the same time as the fire department. EMS noticed that a man, later realized to be the patient's husband, was sitting in a police car. Upon making introductions, EMS discovered that the patient is a 35-year-old female. While actively crying, the patient explained that about 20 minutes prior to EMS arrival, she and her husband were having a "heated discussion" and the neighbor "misread the situation" and called the police. EMS asked the patient how she got the laceration on her head and the patient explained that she was trying to walk away during the argument and her husband grabbed her arm. She explained that as she pulled away, she tripped over a coffee table, causing her to fall into the mirror and smashed her left cheek/face against the mirror, slicing her head on it. The patient denies any allergies to medications, medications taken, or medical history. The patient denies any interventions taken prior to EMS arrival.
Assessment: Patient denied all physical assessments, so EMS only obtained a visual assessment. Patient is AxOx4 to person, place, time, and event with a GCS of 15. Patient was willing to answer EMS questions. Patient has a patent airway and can speak to EMS in full sentences. Patient skin is pink and dry. External bleeding noted by EMS due to an approximate 2 inch laceration above her left eye and a small tear to her left lower lip. No other external bleeding or DCAP-BTLS noted by EMS on patient's visible body (tshirt, long leggings). Patient's breathing is adequate. Patient only describes a sharp-pain headache and rates her pain a 6/10. The patient says that closing her eyes helps with the headache. EMS asked if her pain radiated anywhere else and the patient reported that she also had neck pain, but would not allow EMS to physically assess C-spine for DCAP-BTLS. No injuries noted on visual inspection of neck.
Rx: No treatment provided by EMS. Patient denied treatment, vitals, physical assessment, and transport. Patient condition remained stable and unchanged throughout EMS scene time.
Transport: Patient refused transport. EMS explained to the patient that it is in her best interest to be transported to the hospital by EMS. The patient refused. EMS explained to the patient that EMS is not clearing her from any injury or illness, secondary to this incident. The patient understands. EMS explained to the patient that secondary symptoms relating to head and neck injuries can occur, ranging from serious injury through the possibility of death. The patient understands. EMS encouraged the patient to call EMS again should she notice any symptoms out of the ordinary arise and if her current symptoms do not subside. A refusal form was obtained from the patient by EMS, along with a witness signature by law enforcement.
I: Possible head injury secondary to assault
Student Name EMTB
Texas EMS School
May 22, 2023
We recognize that documenting narratives in CHART format for ER patients can be challenging due to factors such as the fast-paced environment and the potential lack of complete information during each patient encounter. Nonetheless, it remains essential to complete a comprehensive PCR for every patient you claim to have seen during a clinical shift. This includes providing a detailed narrative and documenting at least one set of vital signs per patient.
If you encounter difficulties in gathering information, please document what you were unable to obtain and the reason for it. For example, you might write, "EMS student was unable to obtain a SAMPLE history because the RN requested that EMS quickly take the patient's temperature and report back." This approach ensures that our faculty understand both the reason for the missing information and your awareness of the requirement to collect that information.
CHART Format:
Dispatch: N/A
C/C: This section will be written the same as EMS charts.
Hx: This section will be written the same as EMS charts. but you will not have scene details. Instead, you will write what EMS and/or the patient reports to you about why they came to the ER.
Assessment: This section will be written the same as EMS charts.
Rx: This section will be written the same as EMS charts.
Transport: This section will be written the same as EMS charts, but you will start from when the patient arrives to ER. You may also include if they are discharged or admitted to another unit, if applicable.
I: This section will be written the same as EMS charts.
Student Name EMTB
Texas EMS School