Writing Narratives in EMS || DCHART
There are multiple ways to document/chart/write a narrative 📝, but what information should we include? Below you will find a guide on how to write a narrative using the DCHART set up. I will also put a mock narrative at the end of the post.
🚨*DISCLAIMER*🚨 This is not the only way to write a narrative. If you do not like this way, would not do it this way, know a better way……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? Ask them. If the patient is altered or unconscious, you can note altered mental status or obvious injuries as the chief complaint.
History - This is a perfect place to put your SAMPLE (Signs/Symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up to) & OPQRST (Onset, Provocation/Palliation, Quality, Radiation/Region, Severity, Time).
Assessment - Is the patient A&Ox4? ABCs?🌬🫁🩸 C-spine precautions necessary? 🦽 Is the chief complaint from a traumatic origin? Physical assessment findings? Skin? Lung sounds? Radial Pulses? Results of the 12 lead? Unequal pupils? 👀 Blood glucose level? Temperature? Vitals? Results of palpation? Pain Rating 1-10? Any other assessment findings noted?
To sum this section up, what did you find?
Rx - Patient assessment? Is pt. secure on the gurney? In what position? IV? 💉Blood draw? 🩸Medications? 💊 Oxygen? 🫁12 lead? 🫀 RSI necessary?
To sum this section up, what did you do?
Transport - Code 3 or 1?🚨🚑 Patient’s condition throughout transport? Improvement or decline noted? 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 (you may also place your employee number here)
Here is an example. ⬇️⬇️
D - Atlantis Fire Station 1 is dispatched to 400 N Appleton in reference to a 47 year old female experiencing abdominal pain. Medic 1 responds code 1 from Atlantis Fire Station 1 with 3 personnel (NRP Jackson, AEMT Smith, NREMT White). While en route, dispatch advises that the patient can be found outside the residence. Upon arrival, EMS is directed to the curb. Patient is found standing on the curb, bent at the waist and clutching her stomach. Patient is in obvious distress.
C - Bilateral flank pain and lower abdominal pain
H -
A - Toradol
M - Lisinopril
P - Hypertension & Kidney Stones
L - Breakfast Burrito 5 hours prior
E - Patient stated she had a sudden onset of flank & abdominal pain bilaterally. The patient states that there is blood in her urine & the stream was abnormal because it came out “in spurts.”
O - 1 hour prior while watching TV.
P - Nothing makes the patient’s pain better. Pain is worsened upon palpation and when attempting to urinate.
Q - An excruciating dull pain. (Patient’s words)
R - Left & right lower abdomen radiating to the left & right flanks
T - Pain has persisted in total for one hour.
A - Patient is alert and oriented to person, place, time and event. Airway is patent with no obvious obstructions or excessive secretions. Lung sounds are clear bilaterally. Patient appears to be having no difficulty in breathing and is able to speak in full sentences with ease. Circulation is intact with no external hemorrhage or obvious trauma noted. Pulses are regular at the radial. Patient is visibly upset and crying. Pupils are equal, round, and reactive to light. Abdomen is tender to palpation in the left and right lower quadrants and rebound tenderness is noted. Left & right lower flanks are tender to palpation. Skin is noted to be diaphoretic. Patient confirms a history of UTIs and kidney stones. Patient does state that she is in 10/10 pain even in comparison to child birth. Patient confirms pain upon urination. BGL is 121. Temp is 99.9.
R - Patient assessment is performed. Patient walks to the gurney and moved into the ambulance. In the ambulance, the patient is placed in a position of comfort. Vitals are taken and are as recorded in the report. A 20 gauge IV is established in the left hand and patency is ensured with a flush of normal saline. No redness, tenderness or signs of infiltration are noted to the site. A blood draw is also attained. 50 mcg of Fentanyl is given to the patient for the 10/10 pain. 4 mg of Zofran is given for reported nausea. 350 of a 500 mL bag of normal saline is administered. Patient rates her pain a 6/10 by the time of our arrival at the hospital and is requesting to use the restroom.
T - Patient is transported code one to Atlantis General Hospital. Patient’s condition is monitored and reassessed during transport with slight improvement noted. AGH is contacted via radio and advised of patient’s condition, treatment and our estimated time to arrival. AGH advises no changes in patient’s care. Upon arrival at AGH, the patient is placed in ER Bed 23 and verbal report is given to RN Jessica Smith and signatures are obtained. At this time, patient’s care is turned over to AGH. Medic 1 is cleaned, restocked and returned to Station 1.
Stacee #111 NRP