Triage: Documenting Ambulance Handover.

itsnowornever, BSN, RN · Oct 17, 2012

As someone who had done chart audits for a medical trial...PLEASE!!!!! I have seen too many charts where the intake nurse didn't write ANYTHING DOWN! The scans from the ambulance paperwork are AWFUL and there is MINIMAL information on the MDs notes. :mad: When the company is wrapping up their trial and we are trying to get information it's a bear!

Hooch · Oct 17, 2012

As someone who had done chart audits for a medical trial...PLEASE!!!!! I have seen too many charts where the intake nurse didn't write ANYTHING DOWN! The scans from the ambulance paperwork are AWFUL and there is MINIMAL information on the MDs notes. When the company is wrapping up their trial and we are trying to get information it's a bear!

So in your experience would that mean that the triage nurse would only make a mental note of the information that would be conveyed to him/her by the ambulance crew at triage? Surely, not recording anything would leaves staff wide open legally?

Esme12, ASN, BSN, RN · Oct 17, 2012

Technically the bedside nurse isn't concerned if a drug trail nurse has difficulty auditing a chart (no offense itsnowornever) )Usually the triage nurse is in triage she/he seldom if ever go to the bays unless they were slammed and triage was empty. The triage nurse triage's who presents to the triage desk.

The nurse receiving the patient from the ambulance should document some basics from the EMS but is it "necessary"....that depends on your system of documentation and the cooperation of the EMS. Does every detail need to be documented? Like vitals? NO......arrived with X equipment, IV, meds, monitor, rhythm....chargeable things.

A typical note should read......

Pt arrived via ALS/BLS LSB (long spine board) C-collar intact EMS states patient involved in single car MVC. Car struck tree head on. + LOC at scene starred windshield. EMS sates extensive damage to vehicle with encroachment into passenger compartment of vehicle.....EMS states patient not wearing seat belt......30 min extraction.

Pt states "I hit a tree" LSB/C-collar intact, awake, alert, MAEW, PERLA.....etc. blah .......blah.....Blah

Why do you ask?

Du3du3 · Oct 17, 2012

Im in Palistine and here we dont really have a triage system....

Hooch · Oct 17, 2012

Technically the bedside nurse isn't concerned if a drug trail nurse has difficulty auditing a chart (no offense itsnowornever) )Usually the triage nurse is in triage she/he seldom if ever go to the bays unless they were slammed and triage was empty. The triage nurse triage's who presents to the triage desk.
The nurse receiving the patient from the ambulance should document some basics from the EMS but is it "necessary"....that depends on your system of documentation and the cooperation of the EMS. Does every detail need to be documented? Like vitals? NO......arrived with X equipment, IV, meds, monitor, rhythm....chargeable things.
A typical note should read......
Pt arrived via ALS/BLS LSB (long spine board) C-collar intact EMS states patient involved in single car MVC. Car struck tree head on. + LOC at scene starred windshield. EMS sates extensive damage to vehicle with encroachment into passenger compartment of vehicle.....EMS states patient not wearing seat belt......30 min extraction.
Pt states "I hit a tree" LSB/C-collar intact, awake, alert, MAEW, PERLA.....etc. blah .......blah.....Blah
Why do you ask?

Sheer curiosity - I was reviewing the protocol for triage and it consists of a two pager Q&A that notes the method of arrival, time of arrival, presenting complaint, allergies, obs, GCS, investigations (ECG, urinalysis and tetorifice), pain score, drugs cardex, ABC's, the blaylock discharge planning risk assessment tool, and another section on patient discharge/transfer. It contrasts sharply with the realms and realms of paperwork that's you'd ordinarily end up doing on a ward - and that's in addition to having to do a written summary of the admission.

psu_213, BSN, RN · Oct 17, 2012

We use the same form on our EHR for triaging both ambulatory pts. and ambulace pts. In addition to the CC and a focused assessment of their complaint, the forms asks for prehospital interventions (for a pt brought in by medics this would include IV, CBS, NTG/ASA for CP, etc.). The form also includes an area for a free text note. Here I would document and thing else about the situation. Examples:

--"Medics report visible deformity to right wrist, splint applied by medics to right wrist."

--Pt not on cardiac monitor when brought into ER by medics." (which has happened before with chest pain pts. and even pts. in respiratory arrest)

--Medics transferred pt onto stretcher and left department before giving report to the ER staff (this has also happened, but we have essentially no recourse as the medics here have a very strong union and any complaints against medics go nowhere as the union buries them...oh well, I digress).

itsnowornever, BSN, RN · Oct 17, 2012

So in your experience would that mean that the triage nurse would only make a mental note of the information that would be conveyed to him/her by the ambulance crew at triage? Surely, not recording anything would leaves staff wide open legally?

The information I was looking through was per EMR so I'm sure it was written somewhere! But I don know where. Or verbAlly handed off to someone.

itsnowornever, BSN, RN · Oct 17, 2012

Technically the bedside nurse isn't concerned if a drug trail nurse has difficulty auditing a chart (no offense itsnowornever) )Usually the triage nurse is in triage she/he seldom if ever go to the bays unless they were slammed and triage was empty. The triage nurse triage's who presents to the triage desk.
The nurse receiving the patient from the ambulance should document some basics from the EMS but is it "necessary"....that depends on your system of documentation and the cooperation of the EMS. Does every detail need to be documented? Like vitals? NO......arrived with X equipment, IV, meds, monitor, rhythm....chargeable things.
A typical note should read......
Pt arrived via ALS/BLS LSB (long spine board) C-collar intact EMS states patient involved in single car MVC. Car struck tree head on. + LOC at scene starred windshield. EMS sates extensive damage to vehicle with encroachment into passenger compartment of vehicle.....EMS states patient not wearing seat belt......30 min extraction.
Pt states "I hit a tree" LSB/C-collar intact, awake, alert, MAEW, PERLA.....etc. blah .......blah.....Blah
Why do you ask?

Totally get it! BUT there were times that we had No record of how they were brought in, if it was transport or 911. There was NOTHING

itsnowornever, BSN, RN · Oct 17, 2012

And Esme, no offense taken AT ALL LOL

Esme12, ASN, BSN, RN · Oct 18, 2012

Totally get it! BUT there were times that we had No record of how they were brought in, if it was transport or 911. There was NOTHING

I know you meant no offense. :) The copy of the EMS record may be kept in the ED for 30 days. The permanent EMS run are at the EMS. Depending on policy/state may not end up in the permanent record.

EMTtoRNinVA, MSN, RN · Oct 18, 2012

Here in VA we are required to leave a copy of our EMS run report with the patient's chart in the ED. As an ICU nurse, I appreciate being able to reference the scene notes, but if I don't have them it doesn't change the way I treat my patient. It's the same with interfacility, the sending facility sends really crappy copies of their notes and labs and such and we place those in the back of the paper chart.