Writing Patient Assessment Notes in the Field

by on January 28, 2011

in EMS Tips

How do you write notes in the field? Do you use scraps of paper, a smartphone app, or a tablet PCR?

A new EMT asked me for ideas for tracking the patient assessment details they learned during the patient assessment. I have used a variety of methods.

1. Paper notepad. My favorite has always been the pocket-size paper note pads handed out as a promo item from the local flight service. The pad easily fits in my pocket. The pre-printed fields remind me to capture essential information. I can write additional details on the back of the page. Most importantly if I leave the whole pad sitting on the desk in the hospital EMS office or on the action desk of the ambulance it’s not a big deal.

2. Waterproof pad. I have also used the Rite in the Rain EMS Notebook. I like the fact that as the name says this is a waterpoof and durable paper. It is also a perfect pocket-size for the front pocket of my uniform short. The fields for writing patient information are small so I need to be deliberate about what I write and how I write (quality).

3. Smartphone app. I have not used a smartphone app for tracking patient vital signs and documenting other information, but I know they exist. Everyday EMS Tips review of the EMS Tracker App.

4. Patient care report. When I used a hand written patient care report I would write information into the fields as I worked through the patient assessment. I have not used an electronic PCR that flowed well enough to document information in the PCR as I did the assessment. Instead I write on a paper pad and then transpose to the ePCR after the call is over.

How about you. What do you use to capture patient assessment information as you learn it?

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  • Wyoskibum

    For the longest time I used to use a piece of 3″ cloth tape on my leg.

    • http://everydayemstips.com Greg Friese

      Are you using something different now? I always thought writing on gloves or tape looked a bit messy.

  • http://www.emspads.com Frank Sloan

    emspads.com has the paper pads if you can't get promo ones. I use them everyday.

    • http://everydayemstips.com Greg Friese

      Thanks for the tip Frank.

  • http://www.emspads.com Frank Sloan

    I've definitely used the tape method when the notepads got left in the hospital. I like the notepads because they help guide, IE remind you to check for JVD, assessment offers so many windows into what is going on with the patient, I like having a blank to fill out that reminds me of assessment areas. I think an app could do the same thing, but I don't want my patients “fluids” on my phone, and if they get on paper, I just toss the pad and go on with my life.

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  • Jason

    One word:Gloves.

    • http://everydayemstips.com Greg Friese

      Will have a post soon about my thoughts on gloves.

  • http://www.medicmadness.com Sean Eddy

    I have a printable 3×5 assessment card that you can download for free in the “downloads” section at medicmadness.com. Just print it out on a 3×5 note card.

    • http://everydayemstips.com Greg Friese

      Sean, thanks for sharing the resource. Interesting and reassuring that the Droid Medic still rocks it old school on a note card.

  • http://roguemedic.com/ Rogue Medic

    I print out an ECG strip and use the back of that. If it has HR, BP, and SpO2, then I have a lot of information on the other side and I can keep track of which strip goes with which patient, especially when the clock setting is off.

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  • http://twitter.com/jeffmedic Jeff Anderson

    I used to keep blank paper in the PCR clipboard to take notes on.  Now that we use computers, I have a regular clipboard with a letter-sized legal pad on it.  

  • Cbskywarn

    Zoll easyPCR is an amazing app. It even includes a section for signatures. Only downfall, there is no way to print the PCR’s…yet.

  • Bill Kanoff

    After years of trying to read my scribbled notes, and keeping them organized in the wake of numerous back to back calls, I have converted to a Smart-Phone App called EMS Notes. This was one of the best Apps that I’ve added to my collection. It is well designed and very easy to use. Combine it with the Code Summary, and organization is simple.

    In the past, I used tape, but that often got stuck together and made a mess of my uniform. On occasion I used to write on my gloves, but would always throw them away before transcribing the notes.

    If I am in a real rush with a “sick” patient, I will write quick notes on the pillow case or sheet of the litter. These are easily transcribed enroute to or at the hospital.

    • http://everydayemstips.com Greg Friese

      Bill, thanks for sharing the usefulness of a smartphone app. I also think tape is messy and gloves to much risk of throwing away.

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