EMS Chart Narrative
Seeking a simpler, more effective way to write an EMS narrative? Optimize your practice management using our EMS Chart Narrative Template!
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What is an EMS Chart Narrative Template?
An Emergency Medical Services (EMS) narrative is a form of clinical documentation completed following dispatch and before hospital care. As an essential medical document, an accurate EMS narrative is vital for safe and efficient transitions of patient care (Alatis et al., 2020). To enhance the accuracy of the narrative, we have constructed an EMS Chart Narrative Template to support EMS officers in their documentation and ultimately enhance patient care.
In many nations, such as the United States, clinical documentation of the patient’s initial condition, dispatch details, and care administered by first responders and EMS officers, patient statuses, and treatment responses are required in practice (Short & Goldstein, 2022). However, these can often be time-consuming and lack the detail necessary for efficient patient care (Alatis et al., 2020).
The template operates as a structure to record patient data that may inform practitioner decision-making, diagnosis, and treatments once the patient has transitioned to hospital care. This typically includes the following:
- Patient Information (name, date of birth, age, gender)
- Chief complaint
- Dispatch details (date, time, location, officers involved)
- An initial incident report
- Dispatch procedures (medical procedures, initial assessment)
- Vital signs (blood pressure, level of consciousness)
- Physical examination (injury, substance use)
Depending on the EMS protocols and preferences, the template can be accessed and completed either electronically or by hand using a physical copy.
By completing an EMS narrative, EMS officers can effectively provide patient care details to be passed onto subsequent health professionals whilst keeping documentation essential for medical billing, legal requirements, registries, research purposes, and patient care improvement procedures (Short & Goldstein, 2022).
Downloadable EMS Chart Narrative PDF
Check out our free EMS Chart Narrative PDF here
How does it work?
The EMS Chart Narrative Template provides EMS officers a structure to complete their narrative. To show you how this works, we have broken down the process into the following steps:
Step 1: Obtain the template
Access the electronic copy of the template here, or download a printable PDF using the link below for a physical reference
Step 2: Patient information
If the patient can respond, complete the patient’s personal information details, including their name, age, and emergency contact. This helps inform accurate patient records.
Step 3: Document dispatch details
Summarize the incident details that triggered dispatch, including location, dispatch number, time, and initial observations. This is essential for legal requirements and may contextualize the patient’s condition and inform treatment.
Step 5: Arrival details
Describe the conditions, initial assessment, and procedures conducted before and upon arrival. These can help professionals understand the severity of the incident and procedural treatment.
Step 6: Record health status
If the patient is able to respond, note the patient’s health status regarding previous history, medications, allergies, and the chief complaint.
Step 7: Record vital signs
Document the patient’s vital signs, including the level of consciousness, speech, heart rate, blood pressure, respiratory rate, skin conditions, and any further details regarding their status.
Step 8: Document the treatment
Record any treatments or procedures administered by EMS operators, including medications or immobilization techniques.
Step 9: Document changes
Note any changes to the patient’s health status in response to treatments, including any improvements or changes in symptoms.
Step 10: Transport details
Document the type of transportation used for transitioning the patient to the medical facility, along with the EMS personnel present.
Step 11: Transition
Pass on the EMS narrative to receiving health care providers.
EMS Chart Narrative example (sample)
To show you what an EMS narrative looks like in practice, we have constructed an EMS Chart Narrative PDF. This sample uses the steps above to create a narrative for a fictional patient and EMS incident. It is recommended to use the example as a reference when completing your own narrative. However, this should not supplement real narratives nor be used to govern EMS procedures.
You can view the sample here or download a PDF copy for physical reference using the link below:
Download the EMS Chart Narrative example here.
When would you use this template?
The EMS Chart Narrative Template can be used to structure an EMS narrative for a patient for any type of incident requiring an EMS call. Some situations in which this template may used include the following:
EMS Dispatch use
The template can be applied in on-site EMS call-outs. It helps track essential information regarding pre-arrival and post-arrival procedures in a logical, organized order that is optimal for handoff.
Patient status during transportation
The EMS Chart Narrative Template is an effective resource for documenting patient care and changes in health status during transportation. This helps monitor essential details, such as vital signs, treatments, and conditions that are vital to informing oncoming health professionals.
EMS assessment
The EMS Chart Narrative Template may guide compliance of EMS personnel in regard to response time standards and procedural requirements. There are usually minimum EMS personnel requirements in many states and nations, and compliance can be assessed using the EMS narrative produced (Wolfberg & Wirth, 2005).
Clinical documentation
The template provides an organized structure for accurate and thorough patient records. Ensuring accurate patient medical records is essential and can often govern patient treatments in health centers such as emergency departments or trauma centers (Wolfberg & Wirth, 2005).
Health center emergencies
The EMS Chart Narrative Template may also be useful in health centers, such as clinics and hospitals, during an emergency. It provides a structure that guides accurate recording of patient details, interventions, treatment responses, and changes in health status.
Benefits of the EMS Chart Narrative Template
In using our free EMS Chart Narrative Template, health practitioners such as EMS personnel can optimize their approaches to clinical documentation, ensuring accurate patient records and efficient patient care. Here are some benefits of the template:
Accessible
Given that the EMS Chart Narrative Template is easily accessible online, depending on their preferences, EMS personnel can obtain the template electronically or download the PDF version to have a physical copy.
Efficient clinical documentation
A detailed EMS narrative is essential in health care, as it provides information for patient transitions to health centers and covers the protocols taken by EMS personnel while the patient is under their care. This information is critical for patient records and may guide future decision-making around treatment.
Records for financial reimbursement
Using our template, EMS has thorough documentation to clarify details and enhance communication regarding billing and reimbursement.
Legal documentation
Using the EMS Chart Narrative Template, EMS officers and surrounding medical professionals have an accurate patient record from the incident until the dispatch transition. Having a thorough account of this information is essential for legal matters surrounding patient matters, as this can be used as evidence to support or deny claims regarding patient care.
Why use Carepatron as your EMS Chart Narrative app?
As the ideal way to manage your clinical documentation, Carepatron’s EMS Chart app and software have all of the resources and information you need!
At Carepatron, our vision is to provide practical solutions that optimally save time and resources usually taken by normative clinical practices. This allows health practitioners to focus on providing their patients with the best experience possible. Using our EMS Chart Narrative app, practitioners receive ongoing resources, like the template in this app, to help manage clinical documentation.
Being an online platform, our technology provides ongoing access to information and resources to health practitioners such as EMS personnel and emergency department physicians involved in the patient’s transition to the health center. This allows practitioners to access their patients' records, including EMS narratives, which is essential to well-informed decision-making and proactive patient care required in emergencies.
Patient care relies on effective communication between practitioners when transitioning from EMS to health centers such as clinics and hospitals. Carepatron can help enhance communication and collaborations between professionals by allowing the sharing of EMS narratives, patient medical histories, and treatment procedures on demand. Yet, patients and practitioners can be assured that information stored within the app and software is kept safe, in compliance with worldwide security requirements.
Begin optimizing your practice and enhancing patient care with Carepatron today!
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). Use and implementation of 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
Short, M., & Goldstein, S. (2022). EMS Documentation. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK448107/
Wolfberg, D. M., & Wirth, S. R. (2005). Five good reasons for better EMS documentation. EMS World. https://edcgov.us/government/ems/pdf/documents/RequiredReading.pdf
Commonly asked questions
An EMS Chart Narrative can be easily created by using our template! The template provides an easy-to-follow structure that organizes all necessary information neatly and logically.
EMS Chart Narrative Templates can be used for a variety of scenarios relating to effective EMS documentation of patient care. This resource is typically used during EMS dispatch or health center emergencies.
The templates are used as a roadmap that helps EMS personnel construct their EMS Chart Narratives. These templates structure all necessary information, allowing professionals to fill in information related to each section simply.
An EMS Chart Narrative Template is primarily completed by an EMS officer involved in the patient’s care during and following dispatch.
