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?