Documenting Report from EMS Contact

[Music in My Heart]

I work in a small ER that relies a lot on tribal knowledge and experienced nurses. Being pretty green still, particularly in the ER, I'm still trying to find ways to become more efficient and provide better care to my patients and better service to the folks with whom I interface.

One of the shortcomings that I see is that we have no place on our charts to document report from the ambulance crews. I find myself scribbling notes on post-its and then providing verbals to the docs and then trying to cram it all into my narrative. Things fall through the cracks, though, especially when it's busy and I'm dealing with multiple ambulances at once (only one RN per shift).

I've been trying to put together a sheet to document EMS report but it's pretty slow going. Does anybody have a sheet that they could share which I could use as a starting point?

[Emergency RN]

The question that immediately comes to my mind is, what ever happened to the Ambulance Call Report (ACR, or document which every EMS crew is supposed to file and leave a copy of upon arrival at the ED)? As a matter of protocol it has all info regarding their patient contact; including time of call, what they found, what they did, and who they turned the patient over to in the ED. It's all a part of their continuity of care. I really don't see why you need to duplicate any of that onto your ED paperwork as it would be a needless and time costly redundancy.

In our ED, the EMS crews who use electronics will fax their report, which is then printed out from our printers upon their arrival. Those that are still using Fred Flintstone tech, will hand over a paper copy of their report. We then immediately scan either into our computer charting so that any RN or MD can then call up the image immediately from anywhere where they can access the hospital network, even from home.

[ImThatGuy, BSN, RN]

When I got out of EMS there was no more report to provide to the hospital since everything was completed in the field on a ruggedized laptop. We'd always call into the hospital enroute (me in back usually or the driver up front) to report the patient's complaints, MOI, vitals, IV, oxygen, meds, SAMPLE, OPQRST, etc.

I found that across the state be it emergency or transport that people in the hospital never paid any attention to it anyway, lol.

[GM2RN]

The question that immediately comes to my mind is, what ever happened to the Ambulance Call Report (ACR, or document which every EMS crew is supposed to file and leave a copy of upon arrival at the ED)? As a matter of protocol it has all info regarding their patient contact; including time of call, what they found, what they did, and who they turned the patient over to in the ED. It's all a part of their continuity of care. I really don't see why you need to duplicate any of that onto your ED paperwork as it would be a needless and time costly redundancy.

In our ED, the EMS crews who use electronics will fax their report, which is then printed out from our printers upon their arrival. Those that are still using Fred Flintstone tech, will hand over a paper copy of their report. We then immediately scan either into our computer charting so that any RN or MD can then call up the image immediately from anywhere where they can access the hospital network, even from home.

EMS doesn't usually get their report to us in time to be useful in the ED.

Our software provides space for HPI in narrative during triage, which is where I write what EMS reports and what they did for the pt PTA in the ED.

[danh3190]

In the old old days we (EMS) used to handwrite our trip sheets and hand them in before leaving the hospital. Nowadays we write a short form sheet with vitals, meds, allergies, complaint, and some notes of the exam. Our actual trip sheet gets done on the computer sometimes hours or even days later. The RNs would have no access to the computerized trip sheet that has all the info on it.

[Music in My Heart]

Thanks for the input, folks.

1) We are using Flintstone technology, as are the EMS crews. No computers, just paper and pen.

2) The medics do prepare their own run sheets but they are typically scribbled, full of abbreviations, and very hard to follow -- they will leave a copy if asked but they're not very useful. I believe that the medics use them to recreate a formalized sheet for their records once they're back in quarters.

3) My initial contact is by radio and I begin notes then... it would be nice to start my sheet with a time of initial contact and expected ETA and then go from there.

4) We highly value our medics and what they report. Most of them are great and we rely on their input.

It's looking like I'll have to bite the bullet and make up my own. Still hoping...

[nurse2033, MSN, RN]

Just make a Word document with lines to write all pertinant informaiton such as events leading up to 911, mechanism of injury, check off boxes for IV, drugs given ect, lines for meds allergies and history. A few other odds and ends and you're done. We use a form like this for all ambulance patients that stays with the patient chart. We add the EMS run sheet if it is available. Getting admin to use it could be a challenge. I would ask if you make up your own, could you use it? At least you would have a good cheat sheet for yourself, even if it is not placed in the record. Once people see it they might like it. Good luck.