EMS Chart Narrative

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 patient care transitions (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, care administered by first responders and EMS officers, and patient statuses and treatment responses is required in practice. Moreover, these patient encounter records, though formatted in various ways, are crucial for patient care and should include demographics, vital signs, assessments, and details of interventions (Short & Goldstein, 2022). However, these can often be time-consuming and lack the detail necessary for efficient patient care. 

The chart narrative EMS 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.

Depending on the EMS protocols and preferences, the template can be accessed and completed 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 while keeping documentation essential for medical billing, legal requirements, registries, research purposes, and patient care improvement procedures. Essential components of an EMS report include the patient's demographic details, vital signs, assessment, and any treatments or interventions provided (Short & Goldstein, 2022).

How does this EMS Chart Narrative Template work?

The EMS Chart Narrative Template provides EMS providers with 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

You can access the electronic copy of the template or download a printable PDF using the link we've provided for a physical reference.

‍Step 2: Fill out patient information

If the patient can respond, complete their personal information, including their name, age, and emergency contact. This helps ensure 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 4: Note arrival details

Describe the conditions, initial patient assessment, and procedures conducted before and upon arrival. These can help professionals understand the severity of the incident and procedural treatment.

Step 5: Record health status and vital signs

If the patient can respond, note the patient's health status regarding past medical history, medications administered, allergies, and the chief complaint, such as altered mental status. Document the patient's vital signs, including the level of consciousness, speech, heart rate, and blood pressure. Also, check for obvious respiratory distress, skin conditions, and any further details regarding their status.

Step 6: Document the treatment and patient response

Record any treatments or procedures EMS operators administer, like pain management medications or immobilization techniques. Note any changes to the patient's health status in response to treatments, including any improvements or changes in symptoms.

Step 7: Log transport details

Document the type of transportation used for transitioning the patient to the medical facility, along with the EMS personnel present.

Benefits of the EMS Chart Narrative Template 

In using our free EMS Chart Narrative Template, health care providers 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, EMS personnel can obtain it electronically or download the PDF version to have a physical copy, depending on their preferences. 

Efficient clinical documentation

A detailed EMS narrative is essential in health care. 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 treatment decisions. 

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. 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.

References

Alatis, A. S., Monahan, M. B. V., Raymond, M. A. D., Hudson, M. K. B., MD, Vieth, C.-S. J. T., Nable, Mbc. J. V., MD, & NRP. (2020, February 25). Checklists improve EMS documentation. The Journal of Collegiate Emergency Medical Services. https://www.collegeems.com/checklists-improve-ems-documentation/

Short, M., & Goldstein, S. (2022, September 26). EMS documentation. StatPearls Publishing. https://ncbi.nlm.nih.gov/books/NBK448107/