CHART/SOAP Notes

[usrmebe]

Hey guys. I'm a new EMT and will be working on a BLS service primarily doing patient transports and transfers (inter-facility transfers, hospital to home, etc.). Can any of you provide a CHART or SOAP template or example for how to document these transports? I feel like there's not really an assessment besides vital signs and I'm not sure how to write one of these in general.
Thanks!

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[frosted2]

@usrmebe
I am the rarity among co-workers, but I write everything about the run, even if it is a BLS transfer (some people will literally write "BLS transfer without incident"... really?! lol)

What documentation program are you using? ESO? Paper charts? Feel free to PM me if you ever need help I have never had luck with the SOAP/CHART method, because I feel like (for whatever reason) I need to document how we move the patient to and from each place.

Example:


"

Medic 1 dispatched to best nursing home ever for a 99 YOF, C/C abnormal labs. Upon EMS arrival, patient is found supine in bed. Patient is in no apparent distress, has no life threats and is alert and oriented x 1 (oriented to self) with no complaints of injury or illness. Patient is moved to EMS stretcher via draw sheet without incident and secured with all belts. Patient is moved to med unit without incident.

Once in med unit, baseline vital signs are obtained per chart. Physical exam is performed and is as noted per chart. Patient has no changes in their condition for the duration of the transport. (Report called into destination en route if they make you do so).

Upon arrival at destination, patient is moved to ER stretcher via draw sheet without incident. Verbal report/hand-off given to nurse and signatures for service are obtained. Medic 1 returned to service with no further.

"


This is the assessment tab I am referring to in ESO (images from a powerpoint on Google). If this is the program your company uses, this is what I am referring to when I say "per chart."

I hope that helps a little bit! Again, feel free to PM me if necessary

 

[usrmebe]

@frosted2 Thank you so so so much for this information! I'm going to be starting out on paper charts. Do you do a full physical examination on BLS transfers, like in terms of palpating the abdomen and stuff like that?

 

[frosted2]

@frosted2 Thank you so so so much for this information! I'm going to be starting out on paper charts. Do you do a full physical examination on BLS transfers, like in terms of palpating the abdomen and stuff like that?

No problem at all! Happy to help I do a full exam on every patient. Is it as thorough as a physical exam that I would perform on a 911 call? Absolutely not. I will do a quick HEENT exam (no facial droop, no obvious pupil abnormalities, no JVD/tracheal deviation), listen to lung sounds, palpate the abdomen, and do a quick "trauma-like" assessment of the extremities to feel for any DCAP-BTLS.

Is it overkill? Sure. But the more comfortable you get doing a hands-on exam, the easier it will be when you transition to a 911 truck and then eventually medical school! I have seen some techs that know the book stuff but are terrified to touch people. Easiest way to get over your fear (if you have one) is to have granny Gertrude from the SNF be your opportunity to practice a good PE... I doubt she will care It takes all of 2 minutes to do a quick once-over. So long story short, yes, I'd recommend it