r/ems • u/toinfinityandy • 1d ago
"Don't Put That in the Chart" vs. Neurosurgery
A neurosurgeon that I know at the hospital granted me some sanity on charting and attention to detail recently.
Everybody here brings different sets of experiences to EMS. Some of us grew up around people with certain medical problems, like maybe seizures or kidney disease or alcoholism, or we may have health problems ourselves. We may know more about some random aspect of EMS just because of life happening to us, and this may give us a leg up on helping certain patients better than others.
In both the hospital and on the ambulance, I used to make a point to repeat my patients' symptoms in detail to other people, especially if it was neuro, psych, or musculoskeletally related. An athlete broke their leg and has sensation in just their big toe but not the others? Cool, let's put that in that chart. A seizure patient is seeing red and blue swirls and hearing buzzing 2 minutes before their seizures? Put that in the chart. I would make a point to tell the nurses and docs at the hospital these same details on hand-off, even if I got a weird look. I figured that these kinds of things matter to their doctor, who has to call the shots on a near stranger's health.
I don't know about you guys, but some of the folks that I have worked with have treated me like I'm naive for caring about these details. There's a retort of, "Oh, you don't have to put that in the chart. It doesn't matter." Or, "You can just put 'toe numbness' down." More ER and floor nurses than I would have expected take this approach as well. The lack of care for detail is a bummer, because I know from my biology and neuro background that all of this shit is connected. The kidneys affect the heart affects the brain affects the immune system, and it goes on and on. Details matter, and putting them in the chart matters. Like, why even have this job or keep taking CMEs if I just to write on every little grandma's chart, "RLQ stomach pain x3 days," and then go fuck off to the station and take another nap? There's more to this patient's story, even if I am technically allowed to forget that they exist once I clock out.
Anyway, I was talking to one of the neurosurgeons at the hospital about one of their patients as they were reviewing the chart, and the reports from all of that patient's multi-physician team were insanely detailed. It was stuff like, "Experiences psychosis after eating bread," and, "Sees red and green blocks in upper left of field-of-view in morning only." It was unreal. Just wildly detailed things that were written exactly how the patient experienced them. No vagueness. No judgment or laughing about the patient "making things up" at the nurses' station. Just attention to detail and trusting the patient.
I looked at the doctor and asked, "You guys care about this stuff?" The doc said, "Yeah, absolutely. If a person usually hallucinates red and green shapes before brain surgery, but now they're seeing blue and yellow shapes after, we need to know. Maybe we have to go back in or change their meds." I told the doc that more folks in EMS than they would have guessed have expressed irritation about noting these kinds of things, but the doc said, "If I read something that detailed in an ambulance report, I would want to know where they worked, so I could give them a prize."
I don't know your experiences in EMS. Maybe you have worked at places that championed detailed charting and Michelin star medicine. I'm also no medical genius, and I have much to learn. The medics and nurses who chastised me about charting also taught me other cool things that my dumb-ass didn't know. Some medics and nurses were also just as jazzed about the details as I was. With that being said, this conversation with the neurosurgeon showed me how EMS and ED charts matter and that the details that our patients tell us can actually help their doctors fix them. It didn't feel like my extensive charting marked me as some greenhorn EMT grad at that point. Our charting of some seemingly superfluous symptom may actually change our patients' treatment weeks or months down the line. If some salty bastard is going to make you feel like a gullible child for caring about that and being curious about your patient, then that is their own prerogative.
Does this fit with your experience? What do you guys think?
Note: slightly changed details about the patient and the doc, because HIPAA/PHI.
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u/flaptaincappers Demands Discounts at Olive Garden 1d ago
Ive found that any provider who tells me details don't matter, aren't a provider I would trust. Details do matter. Chart narratives matter. You're painting a picture for someone else to try and understand, have some pride in that.
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u/Far_Paint5187 1d ago
This. As a basic there isn’t that much I can do. Aside from a select few calls where I can actually use basic skills, I’m a glorified Taxi driver. If want to be respected as a medical provider I should think and act like one. The least I can do is chart like one. I look at my job as fact finding. I can’t necessarily fix your weird chronic pain. But I can dig in and ask questions where even a doctor will just ignore you, write prescription, and walk away. If all I’m expected to do is assess and chart, then the least I can do is do so with the most professionalism possible.
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u/Color_Hawk Paramedic 1d ago
I used to have really detailed narratives but my current provider hates “double charting” and if the narrative contains a lot of stuff that’s already been stated elsewhere in the report via event logs or drop down boxes then they deduct points during weekly QI report audits.
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u/zion1886 Paramedic 22h ago
But what does deducting QI points even mean in the long run? Do they take away your good noodle stars?
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u/cyrilspaceman MN Paramedic 22h ago
But all of the assessment choices suck, especially for neuro. If your QI folks ding you because you click the "chest pain radiating to back/arms" button and then detail why that made you think that it was a dissection in the narrative, then they can go eat a bowl of wasps.
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u/TheRedNeuron 1d ago
Agree! For me personally, as someone who sees patients in the ivory tower after all the hard stuff is done, it’s very helpful to know what the initial presentation and thought process was. It helps us (or me at least) to better understand how the disease/injury process has changed or not (with or without intervention).
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u/Delicious-Pie-5730 1d ago
I always give word for word what the patient said, because I don’t know what I don’t know (“my left toe feels like it’s been lit on fire and oh yeah I went to Honduras a week ago if that matters” may be a super obvious diagnosis that would otherwise be missed without those details) and part of my job is being a patient advocate by telling doctors and nurses what the patient told me, in case they may not be given the time or patience to explain it again in the detail they gave to me. I also get eye rolls or annoyance pretty often, but at least I know I told them all of the information I have. I sleep well at night.
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u/boomrostad 1d ago
Or the patient may have a different rapore with medical staff in a hospital setting than they would with you. Absolutely chart it. Chart it all. CYA. Don't let someone's incompetence further down the line of treatment make you look bad because they weren't paying attention... but also... your patient outcomes will be better.
And patients aren't perfect. They may not remember the weird detail when talking to one provider but recall it later on when speaking with another.
Puzzles are easiest to put together when you have all the pieces.
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u/JohnKuch EMT/🚁 Dispatch 1d ago
As an EMT turned EEG Technologist, the little details about a seizure can be so crucial to helping the multidisciplinary care team to assessing seizure potential.
When I read a chart that says the patient has twitching bilaterally, I assume it is synchronous and is possibly a seizure. When it says it's bilaterally asynchronous, that suggests to me it's likely not a seizure.
Another example, the patient turned their head to the left and had a leftward gaze at the start of their seizure. This suggests to me that the seizure started on the right side of the brain--a focal seizure that generalized. Way different consideration than a generalized seizure from the start.
I applaud any EMS provider that provides these little details: it can help speed a patients treatment.
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u/TotallyWizard88 1d ago
I’ll leave you with this, “attention to detail is the difference between good and great”. Attention to detail is the reason you may catch the silent STEMI, or help the medical team understand a patient’s initial presentation, which may influence their ultimate diagnosis. Details do indeed matter.
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u/Ben__Diesel Paramedic 1d ago
Other than ER Techs, in what context is a pre-hospital provider's charting going to be reviewed by an inpatient physician? Ive always assumed the only people reviewing my narratives are QA and the lawyers representing me and my patients.
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u/IzzieR6 EMT-B 1d ago
At least in my area, there is a system that takes EVERY EMS report and logs in it with the PT’s chart onto EPIC. I was looking over a PT’s chart one day and in the bottom of one of the EMS charts it said something about “PT complains of muscle spasm of the left upper extremity” then there was an addendum that said, “PT’s muscle spasm displays as vulgar gesture to providers intermittently”. Wayyyyy more people read narratives than you’d think, I’m just a tech 😂
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u/NapoleonsGoat 1d ago
Your charts are reviewed by many more people than you know. Especially on specialty patients i.e. trauma.
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u/SliverMcSilverson TX - Paramedic 17h ago
At my old shop, whenever we completed our chart on the ePCR, it got transmitted to the hospital we transported to. There, it's uploaded into the patient's chart. When I've spoken with the EMS coordinator at the local level 1, he showed me how easy it is to pull up our charts, and that many different physicians review them, especially on critical patients, to better understand the condition they were in prior to arrival
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u/Blueboygonewhite EMT-A 16h ago
I do EMS research and regularly read EMS charts. It may not directly affect care but it may indirectly if we are getting bad data.
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u/Dangerous_Strength77 Paramedic 1d ago
I've always put the details, as well as directly quoting the patient wherever it is appropriate. Details do matter. People who use the single four line paragraph narrative format? Well, I have some things I'd like to say to them.
Including details may not make us popular at station, but when the doctors start running you down to get report from you? OP, you'll know you've been doing the right type of charting.
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u/RocKetamine FP-C 1d ago
100% fits with my experience, as well.
This is a symptom of an American industry that basically has no barrier to entry and no legitimate educational requirements. Yes, there are nurses and physicians that chart like shit, but (IMO) it's far more widespread in EMS.
Those people are also usually the most obnoxiously vocal about the shit pay in EMS. They'll lock charts that reads like a 4th grader wrote it with absolutely no useful information. On their phone 24/7, but don't seem to use the phone to look up how to spell words. Yet, they remain puzzled as to why they don't get raises.
If you consistently write and sign shitty charts, then you are probably a consistently shitty provider.
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u/SliverMcSilverson TX - Paramedic 17h ago
pt suffering from asshma exasperation, performed VOMIT and gave neb fin
ALL TIMES APROXEMATE
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u/pr1apism Band-Aid Applier Instructor Trainer 1d ago
ED attending and former EMT chiming in.
Attention to detail is awesome and can make a huge difference, especially for neuro symptoms that can help localize where there is an issue.
The flip side to this is a report that is overly detailed can become convoluted and hard to decipher what is important and what is bloat. The longer a report or note is, the more likely I am to skim or skip it.
One of the most important skills in medicine is learning how to pick out what is important and what isn't when giving a report. For instance, I don't need to know the exact time and dose every time a patient has taken motrin over the past 5 days. I do need to know the most recent time.
You might be getting eye rolls if your report takes forever because it's bloated with detail. That's somewhat ok because frankly it's my job to figure out which of these details is important. So giving more detail is better than too little.
Hope that helps
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u/grandpubabofmoldist Paramedic 1d ago
If they told you it or you found it in an exam, put it in the chart. If the nurses brush you off, thats fine. Legally you covered your butt by putting it in the written part
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u/ZuFFuLuZ Germany - Paramedic 1d ago
I think the problem is that we are writing all these charts and send them off into the void, never to be seen again. We don't even know if anybody at the hospital will take a look at them. Many are never being read and even if they are, we are never getting any feedback.
So we never know if our chart was good or bad, if it was helpful or not. They don't even tell us if we made a mistake somewhere or if we could improve somehow.
That's why people simply stop caring about it. They just do the bare minimum to save their own asses and send it away.
That being said, I have also seen people do the opposite and write down every single detail of even the simplest call. When you are charting for half an hour for a stubbed toe, you are doing it wrong, too. Nobody will read that. You have to find a middle ground between being thorough and speed.
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u/RonBach1102 EMT-B 1d ago
I’ve been out of the game for 10 years now but I don’t remember any of my charting being looked at by anyone other than QA. But I was IFT so who knows if 911 was different.
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u/amberatx 1d ago
I had 8 years of medical mystery and got to a point of “why even wake up tomorrow”…. Until I found a doctor that asked me sooooooo many questions I would never have considered important. “Did you get warts as a kid?” kinda stuff. SHE is the one that figured it all out and restored my life to the most peaceful and joy filled days I could ever imagine. There are two kids out there that still have their mom bc DETAILS DO MATTER.
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u/ExtremisEleven EM Resident Physician 1d ago
My friend if you chart like you write, you’re adding so much the important details are being lost. Knowing what to chart is far more important than charting bulk because to be honest, the neurosurgeons might want that information but I promise you they are not combing your notes for it. They have their own short form template and they are supposed to be asking their own pertinent details when they see the patient. Save your energy because this will accelerate your burnout.
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u/gowry0 1d ago
I once had a patient that was experiencing urinary incontinence, but he wears a “depends” regularly.
He thought he was coming down with a UTI. Imagine how confusing the hand over was. It got to the point where less was more.
Patient thinks he’s coming down with a UTI… last time he had urinary incontinence like this was because of a UTI….
I get it details are nice, but sometimes too many aren’t needed and more can sometimes be confusing.
Guess what… he had a UTI.
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u/Somethingmeanigful Parababy 1d ago
I’ve always wrote obscure details into my charts regardless if they’re neuro related or not… to be honest with you I’ve always been of the mindset that it’s for the doctor to decide if it’s irrelevant or not, it’s not my job. So if the patient tells me something no matter how obscure, I make a mission to right it down and report it if I remember.
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u/classless_classic 1d ago
Another point- when/if someone pulls charts for data in a retrospective study, some of these details are invaluable.
ESPECIALLY now that AI can read an entire chart in micro seconds and compile/compare data like this, there may be an unseen trend in data that can elude to a symptom that no one has discovered before.
If nothing else, I do it for my own amusement. I love charting odd details that may make someone laugh or even say WTF, when reviewing my charts.
Speaking from a legal background, it rarely hurts anything to add things like this in, unless you are missing an obvious sign/symptom. That’s why follow up calls are important. 😉
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u/goosegishu 1d ago
Chart everything the patient tells you. They often don’t know what matters and what doesn’t so they don’t tell everyone the same story exactly. That’s why every specialty that meets them takes their own history and does their own admission notes.
There’s a reason medical school is 4 years and residency is another 3+ years depending on the specialty. This is not a dig at any other scope of practice at all, all disciplines are important and make the world go round. But if the details didn’t matter then physicians would just need a bachelors or a masters.
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u/GPStephan 1d ago
You work with absolute fucking idiots.
It doesn't take a medical degree, or even a paramedic diploma, to figure out that there is a pathophysiological difference between someone not feeling just their big toe, and someone not feeling any of their toes.
It doesn't take a medical degree to figure out that the type of pain a patient experiences is important, not just that they are experiencing it.
It doesn't take a medical degree to simply quote your patient in your chart. It actually makes things much easier because now you don't have to paraphrase or summarize, just copy what was said.
If anyone at my company expressed these attitudes, quite a few of my coworkers would tell them they are an idiot to their face.
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u/bimbodhisattva Nurse 1d ago edited 1d ago
Same experience, but with psych (bedside). Amazing what just a lil progress note (when something that would be helpful for clarifying symptoms, added in when it happens instead of tacked on as a tiny blurb at end-of-shift) can do. I've been approached about it by some of our docs saying they love it.
Neuro changes also need to be specific. I would do the same thing. I find comments like that super helpful when monitoring for changes or calling the doctor. Keep up the good work :)
Maybe people are giving you shit because it feels unnecessary, but we are closer to the bottom than the top—we don't know what might be super important! They can suck it, lol
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u/PolymorphicParamedic Paramedic 1d ago
I have never worked with someone that said not to document the patients symptoms the way they describe them. What turds are you guys working with? Cause I definitely work with some turds- but we still document things.
I did tell an EMT on training one time that he didn’t need to document if he gave the patient an extra blanket because they were chilly or if they shut one light off because it was too bright. But that’s about it
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u/Melikachan EMT-B 1d ago
If a patient gives me info, I'll put it in the chart. Like you I came to EMS with some medical background and believe the details can matter.
Even if the initial nurse or doc rolls their eyes, it's there on my report's printout and part of their patient file. I've done what I could.
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u/ImJustRoscoe 1d ago
My boss always gives me shit about my detailed narratives but he will appreciate it if we ever get a subpoena or deposed. It does not harm and can only help clarify something someone else may have missed.
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u/McsRn 1d ago
RN here.. Maybe it's a neuro icu thing.... that's how we were when I worked on that unit.... and it absolutely matters. The subtle changes in exam can mean massive changes in the body and catching those things early can make all the difference in patient outcomes.
When I went to work on different units and brought that detail into my reports and patient care, people would just get annoyed. And on thw other hand getting report from those people, I realized, told me nothing about the actual patient status, bc half the time they were playing telephone and didn't actually know how to do their own, thorough exams. The result is shittier care and worse outcomes. It's frustrating.
I think you're doing the right thing, and people might not appreciate it.... as long as the info relayed is actually relevant to what's going on and not just unnecessary gossip/detail. There will be people that do appreciate it though-- maybe just not the ones you're currently working with.
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u/DoYouNeedAnAmbulance 22h ago
I’ve never been told that details don’t matter explicitly. And I always include the level of detail that the patient is able to relay to me. Some can’t even narrow it down beyond “I don’t feel good.” At which point I just fling myself out the back of the ambulance.
I HAVE had handoffs where they seemingly don’t give a flying fuck what I have to say though 🤷♀️I guess they don’t like EMS or are shit at their jobs and need to be focused only on what they’re doing.
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u/Wardogs96 Paramedic 17h ago
It's contextual. Sometimes less is more and other times detail matters.
With experience you learn pertinent negatives, red flags and niche things that should be included in a report. If big dick Rick is coming in for toe pain... No one cares about his bowel movements or urinary output. I don't care about his asthma meds... All I care about is recent injuries, ROM and sensation/strength, exacerbating variables, DM and gout status and if it's controlled, recent A1C for perspective, past surgical history to the area. Also anticoagulation status.
Sadly knowing all those cool details are great for our potato patients but they're potatoes and can't say anything to us.
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u/caelumAurora EMT-B 6h ago
as a Basic and ER tech/monitor tech at a level 1 who LOVES the details also, i’ve had providers come up to me and ask me to remove charting regarding specific heart rate changes and oxygen sat trends (my job) because it would cause other departments to reject the patient’s admission and force them to stay in the ED longer while they restarted the bed request process or managed to convince someone on the service at 2am. All because of attention to detail. And because there are usually 50 in the waiting room and 8 incoming transfers.
I hate the culture so much because details matter the most in patient care and because i have general integrity and may be on the spectrum. It infuriates me to no end but sadly i guess some aspects of hospital culture (the understaffing/increased census/less facilities/increased acuity/less general resources) causes EDs to jump through hoops just to free up a bed space, as if it isn’t hard already.
I think it’s just a symptom of the larger problems increasing in healthcare settings that i’m sure we’re all aware of. At least assuming you’re working around a for profit healthcare system largely focusing on ER interaction.
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u/Thnowball Paramedic 1d ago edited 1d ago
Neuro symptoms need to be narrowed down pretty well. Something as simple as which fingers are going numb can clue you in on whether the median or ulnar nerve is being compressed for example.
I don't always include these kinds of details in my chart though, because for the most part I always get the Forrest Gump type patients who vaguely tell me "I feel bad" then refuse to elaborate or answer any questions about what their actual fucking symptoms are. Then they AMA and walk out the moment we get to the waiting room...