Writing Patient Assessment Notes in the Field

17
493

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?

MedicCast Extra Study Aids