Protocol: Charting

Original Effective Date: 01/01/2001 | Revised Date: 01/01/2002


BLS PROTOCOL

INTRODUCTION:

A copy of the PCR is to be left with the patient's medical record by the procedure of the individual department. This requires that the patient information and narrative be filled out as soon as possible, this will ensure that the EMS component of the medical care is available to the next provider.


PROCEDURE

  1. Complete all appropriate spaces/boxes on the patient care record (PCR).
  2. Use either SOAP or CHART format in your narrative.
  3. The record you fill out should be an accurate recounting of your experience with the patient and circumstances you encountered. Do not use somone else's opinions and or opinions you formed after the fact.
  4. The record should reflect your immpressions and opinions even if they were subsequently found to be incorrect.
  5. The record should accurately reflect your actions.
  6. Ther is no room for Chart Buffing, the practice of making what happened appear better on paper than it really was. You cannot benefit from your mistakes and the quality assurance process if you look perfect on every report.

SPECIAL CONSIDERATIONS/NOTES/CAUTIONS

  1. SOAP format definition:
    1. S - Subjective (what you were told by a patient, bystander, FD, etc.)
    2. O - Objective (what you saw on your arrival through physical exam)
    3. A - Assessment (your diagnostic impression)
    4. P - Plan of Treatment (the care you rendered and patient response to such)

  2. CHART format definition:
    1. C - Chief Complaint (self-explanatory)
    2. H - History (pertinent present and past history)
    3. A - Assessment (your physical exam/assessment, to include clinical & diagnostic assessment findings)
    4. R - Treatment (the care you rendered and patient response to such)
    5. T - Transport (transport mode, level of care provided, destination, and significant changes in patient status during transport)

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