Stroke Narrative || EMS Documentation
Your patient is having a stroke! 🧠⚠️What are important points to document?✍🏻
Most EMS 🚑 professionals have had the call where it is obvious the patient is having a stroke from the moment contact is made. Some are not so obvious…..that will be a post for another day 🙂. There are multiple ways to document/chart/write a narrative 📝, but what stroke specific information should we include?
🚨*DISCLAIMER*🚨 This is not the only way to document a stroke. If you do not like this way, would not do it this way, think this way is trash……that is OK. 🙂
Dispatch Info - What unit are you, where are you and for what you are dispatched? 🚑 Who is responding (provider’s last name & level) and in what manner? What information did dispatch give? You can can insert information about your initial scene assessment and how you first find your patient here if you wish.
Chief Complaint - What is the patient’s complaint? Sometimes (especially with a stroke) a patient cannot tell you their complaint, do your best to document the problem.
History - This is a perfect place to put your SAMPLE (Signs/Symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up to) &
BEFAST (Balance, Eyes, Facial droop, Arm weakness, Speech, Time).
Assessment - Is the patient A&Ox4? Last known well time? ABCs?🌬🫁🩸 C-spine precautions necessary? 🦽Is this from a traumatic origin? Physical assessment findings? Cincinnati (or whichever scale you use) stroke scale findings? Are there deficits present and where? Aphasia or dysphasia present? Unequal pupils? 👀 Blood glucose level? Results of the 12 lead? 🫀 Vitals? Stroke alert activation. 🧠⚠️🚨
To sum it up, what did you find?
Rx - Patient assessment? Is the pt. secure on the gurney? Stroke assessment? 🧠 IV? 💉Blood draw? 🩸Medications? 💊Oxygen? 🫁12 lead? 🫀RSI necessary?
To sum it up, what did you do?
Transport - Code 3 or 1?🚨🚑 Patient’s condition throughout transport? Any delays due to weather, traffic, etc.? Radio report? Where (in the hospital🏥 ) did you take them? What RN did you transfer care to? Obtain signatures?
Your name & EMS level
Click the link for a full video breakdown!
Example ⬇️⬇️⬇️⬇️⬇️⬇️⬇️⬇️