EMS CHART
Elevate your approach to EMS documentation with our EMS CHART Template. This template provides the structure required for a high-quality report.
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What is an EMS CHART Template?
In many nations like the United States, first responders and emergency medical service (EMS) personnel must complete documentation regarding the patient’s initial condition, health status during transportation, and responses to treatment procedures (Short & Goldstein, 2017).
Failing to complete EMS documentation may not only result in disciplinary action but has been associated with poorer patient outcomes, morbidity, and mortality (Alatis et al., 2020; Short & Goldstein, 2017).
An Emergency Medical Services (EMS) CHART template is a resource used to structure and enhance the quality of EMS narratives or reports following dispatch. It uses the CHART documentation method, which stands for complaint, history, assessment, and treatment, to ensure that all essential information is included in the document (Montgomery County MD, n.d.). The structure orders this information and breaks down the required details in each section.
Typically, an EMS CHART would include the following information:
- C - Complaint (the patient’s chief complaint)
- H - History (previous medical history, medications and allergies)
- A - Assessment (physical examination and vital signs)
- Rx - Treatment (treatment procedures and details in order)
- Tx - Transport (transport and transition details)
The template can be completed electronically or printed, and a physical copy can be completed manually.
By using our EMS CHART Template, health centers, and practitioners can enhance their documentation and include all information necessary to inform other health practitioners effectively at handoff.
Printable EMS CHART Template
Download this EMS CHART Template to structure and enhance the quality of EMS narratives or reports following dispatch.
How does it work?
The EMS CHART Template works by organizing all CHART information in order and providing spaces for EMS personnel to fill in relevant patient care details. To show you how this works, we have broken down the template process into the following steps:
Step 1: Access the template
You can access the template online to obtain a digital copy or download a printable PDF version if you prefer completing the template manually.
Download the Printable EMS CHART Template here.
Step 2: Document the chief complaint
The chief complaint refers to the reason for the EMS call-out. This section can include the patient’s chief complaint alongside information from initial assessments that contextualize the situation.
Step 3: Record the patient’s history
If the patient’s circumstance allows it, record relevant medical history and other information regarding their medical status. This updates the patient’s records and may help determine causality.
Step 4: Document assessment details
List the assessment procedures completed during EMS care and the results or findings from these. This may include physical examinations, vital signs, and signs of injuries.
Step 5: Record treatment details
Record the pre-hospital treatments or procedures used. These may include procedures taken before dispatch arrival, such as CPR or Epipen administration, and those born once EMS arrived and during transport. In this section, be precise about the equipment used, steps taken, personnel involved, and other details necessary for the treatment.
Step 6: Document transport information
Ensure that all transport information is recorded, including where the patient was taken, equipment used, procedures, treatments administered, and any changes.
Additionally, it is essential to note any patient responses or refusals to treatment or transport procedures.
Step 7: Review and sign
Review the document critically to add details and check for errors. Complete the template by signing and dating the document.
EMS CHART example (sample)
We have created an example of how the EMS CHART Template PDF works in practice. The example uses fictitious information about a patient in an EMS incident to fill out the EMS CHART.
It is recommended to use this as a reference when completing your template. However, the information in the example should not substitute patient data or be used as an example for correct procedures during an emergency.
You can access the sample here or download a copy to print for a physical reference.
Download the EMS CHART example PDF here:
When would you use this template?
The EMS CHART Template is primarily designed to support practitioners in their EMS documentation. The template can be used to structure any document for emergencies. Situations in which this template may be used include the following:
EMS callout
EMS professionals, such as paramedics, may use the template to document the callout procedures and patient care before the health center transitions. This may help keep track of the patient’s health status and any changes throughout the emergency that can be used to inform patient care.
Furthermore, the template may document important call-out information that can be used for financial and legal purposes.
Health centers
Health centers such as hospitals or health clinics may use the template to standardize their approaches to emergency documentation. This can ensure that all professionals are on the same page and enhance the quality of EMS documentation.
Enhancing protocols
Given the fast-paced nature in which these health facilities operate, emergencies can happen quickly and spontaneously. To monitor these events, it is essential to include all details to develop effective strategies and protocols to address these.
By using the template, health centers can acquire thorough documentation of their procedures, which can be assessed to make any changes that enhance patient care.
Benefits of the EMS CHART
Our free EMS CHART Template uses the CHART method to structure all the information necessary for a detailed, effective report. This simplifies the process for EMS practitioners, allowing them to produce high-quality reports favorable for enhanced patient outcomes. The following are some benefits of using our template:
Time efficient
Detailed EMS documentation requires time and resources, often not readily available given the fast-paced emergency services environment. Our template alleviates these constraints by providing EMS professionals with a ready-to-use structure, allowing them to focus solely on reporting patient information and incident details.
This will enable professionals to optimally save time, allowing them to focus on patient care.
Effective communication channels
By using our template, the communication between EMS officers and receiving health professionals may be enhanced. Often, much of the details reported to receiving health professionals at the hospital need to be recovered in translation, as much of the focus is on moving the patient from dispatch.
Using the EMS CHART Template can help consolidate patient information and provide a reference point to check information that may have been missed in verbal communication.
Accurate documentation
EMS documentation is dominant in patient care, as it informs health professionals of the patient’s health status and frames oncoming treatment procedures. Therefore, all documentation must be accurate. Implementing the template as an assurance tool can enhance documentation quality and ensure that all essential information is recorded.
Why use Carepatron as your EMS CHART app?
At Carepatron, we aim to provide groundbreaking solutions that improve practitioner and patient experiences. By streamlining administrative tasks such as clinical documentation, appointment scheduling, and medical billing, our technology saves time and resources, allowing practitioners to dedicate more time to patient care.
Being an online platform, Carepatron provides continuous access to resources such as this template, facilitating the seamless transition of patient care from EMS personnel to emergency department physicians. This ensures that all necessary information about patient care and health status is available for well-informed procedures.
Designed with a user-friendly interface, our EMS Report Template app enables practitioners to quickly navigate through EMS and patient records. This accessibility supports the proactive patient care procedures essential for effectively managing emergencies.
Collaborative work between practitioners is pivotal during the transition from EMS to receiving health centers, relying on effective communication. Carepatron facilitates this by enabling practitioners to enhance their written communication, ensuring the effective transfer of all details. Additionally, our EMS Chart software enables teams of practitioners to easily share patient notes, EMS reports, and treatment procedures.
Embark on the journey to enhance your practice and elevate patient care with Carepatron today!
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References
Alatis, A. S., Monahon, B. V., Raymond, A. D., Hudson, K. B., Vieth, J. T., & Nable, J. V. (2020). Checklists Improve EMS Documentation. Quality Improvement in a Collegiate-Based EMS Agency. The Journal of Collegiate Emergency Medical Services. https://www.collegeems.com/checklists-improve-ems-documentation/
Chen, C., Kan, T., Li, S., Qiu, C., & Gui, L. (2016). Using and implementing standard operating procedures and checklists in prehospital emergency medicine: a literature review. The American Journal of Emergency Medicine 34(12), 2432-2439. DOI:https://doi.org/10.1016/j.ajem.2016.09.057
Laudermilch, D. J., Schiff, M. A., Nathens, A. B., & Rosengart, M. R. (2010). Lack of Emergency Medical Services Documentation Is Associated with Poor Patient Outcomes: A Validation of Audit Filters for Prehospital Trauma Care. Journal of the American College of Surgeons, 210(2), 220-227. DOI:https://doi.org/10.1016/j.jamcollsurg.2009.10.008
Montgomery County MD. (n.d.). CHART Documentation. Emergency Medical Technician, Maryland. https://www.montgomerycountymd.gov/mcfrs-psta/Resources/Files/ems/emt-class-resources/CHART-handout.pdf
Short, M., & Goldstein, S. (2022). EMS Documentation. StatPearls [Internet].
Commonly asked questions
Generate an EMS CHART effortlessly with our EMS CHART Template! This template compiles all pertinent patient information into a readily usable document.
While applicable in various situations, the EMS CHART Template is crafted explicitly for completing EMS documents.
These templates are valuable for arranging crucial information related to EMS patient care. Practitioners can easily follow the instructions provided in our guide to fill the template sections with pertinent patient details.
