Everyone has their own way of charting. No certain way is the "right way". By utilizing this method initially, one can then expand from it, picking and choosing what is liked.
Chief complaint: What exactly was told to you.
-Ex. Pt. states, "My foot hurts because I tripped down the stairs"
History of present Illness: (HxPI): What happened? Utilize OPQRST. Ex: Pt. relays onset of fall 20 minutes PTA of EMS. She states, "I was walking to get my laundry and slipped on a sock". Go on to included pt. complaints. (include pertinent positives and negatives). Pt. complaint of R generalized foot pain described as "dull pain" Pain rated 8/10 by pt. w/ no radiating pain. Pain is provoked with ambulation. Pt. denies any LOC, dizziness, lightheadedness or hitting of the head prior/during fall. Pt. denies any neck/back/head pain. - ETOH (per pt.) Pt. denies all other complaints besides R generalized foot pain.
MEDS: list pt.'s medications
MEDHx: Include pt.'s medical history
Allergies: list pt.'s allergies (NKA if N/A)
EXAM: This is where you place your physical assessment/head-to-toe. Now, not every patient requires a detailed exam, revert to a focused exam. By walking through this though, it will help with your assessment. Again, this is meant for new EMT's/Medic's that have been scared and manipulated to the point of madness by instructors. Start off on how you found them. Ex: pt. found lying supine on the floor below staircase. How was she? Ex: Pt. was CAOx4. No visible trauma. Mild emotional distress. Now, walkthrough the assessment. Airway patent. Breathing non-labored. Strong, regular, equal radial pulse x2. Skin pink, warm, dry. HEENT: Pupils PERRL. No JVD. No DCAP-BTLS. CHEST: Equal rise+fall. lung sounds C/E bilaterally+present all fields. ABD: soft+non-tender to palpation. No distention, pulsating masses, rigidity. PELVIS: Stable. No DCAP-BTLS. EXT: PMSx4. No EDEMA. Noted swelling to R ankle. No other noted DCAP-BTLS. BACK: No DCAP-BTLS....Since a FAST exam is a finding (along with good glucose), it wouldn't hurt to them in this section. Again, this is just a list for a student that may need a little help with charting.
Transport mantra: This section you will include what you did. Did it improve something? Did it worsen it?. Any new findings during re-assement? Basically, write what went on. Ex: Pt. was secured to EMS cot w/ all straps. Vitals within normal limits. 18 G IV patent in the L AC. Rhythm noted was NSR. 50 mcg of Fentanyl administered SIVP w/ no noted complications. Enroute, pt. informed EMS "my pain is at a 2 now". No other noted changes enroute or new complaints per pt. Upon arrival at (hospital), pt. safely placed in ER (room #). Pt. care+report transferred to (hospital) ER nurse.
-Now, in this section if medical control was contacted (for a trauma or orders), don't forget to log the run # along with the doctors name. If the patient gets worse enroute, document that. It's okay if new findings show a negative trend. Not every patient will get better. For example, a COPD/CHF patient was diminished and you treat them with a Duo-Neb, after they open up it could reveal crackles not wheezes or rhonci. This is okay. Document the findings as a re-assesement. Just always remember to stand by your treatment, justify your actions and be able to accept when you made a mistake.