EMS Documentation Part 2: Pre-arrival

Previously:
EMS Documentation: Introducing Pre-SOAPeD

Pre-Arrival

As I mentioned in the opening, one of the big advantages of a SOAP note is the fact that it’s essentially the standard form of documentation in medicine. However, I won’t argue that there are certain operational aspects of EMS that separates it from medicine. Probably one of the best examples is the fact that an EMS call starts before patient contact. A physician SOAP note’s HPI generally starts out with something along the lines of “a __ y/o M/F with a complaint of ___.” In a hospital, something might be added about how the patient arrived or why they are writing the note (such as a cardiology consult). In EMS, though, our call starts when we are dispatched, not when we arrive. In general, this section is one of the shortest sections. Where are you dispatched to, why were you dispatched, and how are you responding? Yes, I realize that the complaint coming from dispatch often doesn’t match the actual complaint that the patient has, which is of course the entire point of documenting it. Finally, did anything happen during the response? For example, there’s a few major rail lines running through my area and it isn’t unheard of to see emergency units waiting for the train to cross, or in one case leave the station since the arms are down when the train is in station due to the proximity of the station to the street, before they can proceed. It can turn an acceptable 5 or 6 minute response into an unacceptable 10+ minutes.

Pre-arrival: Unit 75 was dispatched code 3 to 1234 Arrow Drive for a patient complaining of chest pain. While en route, we were delayed approximately 4 minutes at an at-grade railroad crossing.

EMS Documentation Part 3: The Subjective

Advertisements

About Joe Paczkowski

I am an EMT and a second year medical student at Western University of Health Sciences, College of Osteopathic Medicine of the Pacific (COMP).
This entry was posted in Clinical EMS, Documentation and tagged , , , , , . Bookmark the permalink.

One Response to EMS Documentation Part 2: Pre-arrival

  1. Oh my goodness! Incredible article dude! Thank you so
    much, However I am encountering issues with your RSS.
    I don’t know why I can’t join it. Is there anybody else having identical RSS problems?
    Anybody who knows the answer can you kindly respond?
    Thanks!!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s