Simply Subjective

Jacky Vaniotis, RN, NREMT-P

Documentation -- say the word and the vast majority of EMTs of all levels roll their eyes and tune you out. Many people look at documentation primarily as a necessary evil, something that must be done because the state says so, something that is done to protect us in the event of a lawsuit, something that is used by those in charge to catch us in our mistakes. It’s unfortunate, because it can and does do so much more than that. Documentation actually improves patient care. When you know you’re going to have to write it down, you ask it, you assess it, and you do it. And when you’ve asked it, assessed it, and done it, then you can write it down. Good documentation leads to good patient care which leads to good documentation…

There are many different formats suggested for documentation, and many arguments in favor of or against each of them. My recommendation is that you find a system that works for you, learn how to use it well, and stick to it. It might mean a little extra work on your part initially, but it will be well worth it. After you come home from your next call, try this: write your report in SOAP format, write it again using CHART, and write it a third time in some other format. See which one works best for you. Try it again on another type of call, and another; see if it works on those kinds of calls, too. Then ask somebody who wasn’t on the call to tell you, based only on what is written on your run sheet, exactly how the patient looked and exactly what happened. See if how you use your chosen format gives a very clear picture.

            I personally use SOAP, but I find that reports written using CHART are also very well done and very easy to read. The only format that I, as a reader, find frustrating (and let’s face it, we should be writing our records for the reader, not for ourselves!) is the narrative. Many people will argue that they always use the narrative, because that allows them to capture everything that happened. Well, if SOAP and CHART aren’t capturing everything for them, then they just haven’t learned to use them correctly. And if you’ve ever been the reader trying to find a specific piece of information in a long narrative, you know the frustration you feel as you try to negotiate through a random collection of information all presented in no predictable, systematic pattern. Remember, if you want something to be read, you have to make it easy for the reader to read it.

            This month I’d like to begin the first of a series of articles on documentation, focusing this time on the subjective components, and in an upcoming issue of this Journal focusing on the objective and treatment plan components.

One thing I have found in reading hundreds of run sheets and patient care notes from providers of all levels from all corners of the state, as well as from students and nurses, is that the subjective information tends often to contain only that information which the patient offered. If the chest pain patient happened to mention that his pain radiated, then it might get written. If the patient with lower abdominal pain happened to mention that he had his appendix removed seven years ago, or that he has asthma, or that he last ate two hours ago, then it might get written. But many EMTs don’t have a systematic approach for asking questions and then for writing the answers down. If they had such an approach, they’d be assuring they get the information they want every time, even if the patient doesn’t happen to offer it on his own.

You already know that the subjective information is what someone else must tell you. But how do you both obtain the information you want and organize it so the reader of your run sheet can easily find what he or she wants to know? Well, you start by asking the right questions, and the mnemonics SAMPLE and OPQRST, taught in all major EMT-B textbooks, remind you of all you need to ask. And these memory aids really do help.

            The SAMPLE history begins with asking about Symptoms, and OPQRST, the format suggested in textbooks to get a picture of the symptoms, really works! Where does any good story start? At the beginning -- the Onset! So you start by asking, “When did this all start?” (Onset) This leads you easily into the next logical question: “And what were you doing when it started?” which leads logically into another follow-up question: “Does anything make it get better or worse?” (Palliation/provocation.) By asking the questions in an order that makes sense to you, you are helping the patient focus on providing you with what you need to know, rather than what he or she thinks you need to know. And you are gathering far more useful information than if you just depend on the patient to figure out what to tell you on his own.

Next ask, “What does the pain feel like?” (Quality) If the patient is not complaining of pain, i.e., if he is only complaining of shortness of breath, the “Q” or “quality” part of OPQRST can still remind you to at least ask if there is any pain, and if so, for a description of it. That description would also include Radiation. “Does the pain go anywhere else, or does it stay right there?” But maybe the patient answered negatively to the question about pain. When questioned further, however, about pain anywhere else, he might mention a pain that he’d been feeling for a couple of days and hadn’t told you about initially, because he didn’t think it was related to his current symptoms. Think about the elderly hip fracture patient whose only complaint is knee pain but who, when asked about hip pain, will remember that her hip did hurt when she tried standing up, even though it doesn’t hurt now.

Continuing with your history, you ask, “On a scale of 0-10, with 0 being no pain at all, and 10 being the worst pain you could ever imagine, what number would you give this pain now?” (That’s Severity) What the pain is like right now is important, but so is what it was like at its worst, so ask about that as well. It’s also important to advise the patient that you will be continuing to monitor his pain on this scale, as will the staff at the hospital, so that if the pain should go up or down a notch, he should let you know. Many pre-hospital people aren’t aware that many hospitals are now using the 0-10 (or 1-10) pain scale themselves, in both their outpatient and inpatient settings. Just like our baseline vital signs start the monitoring for trends, so does our monitoring on the pain scale.

The last part of the OPQRST mnemonic is Time. Well, you’ve already asked about when it started, you’ve asked about whether or not it has gone away during that time (palliating factors) but what you still don’t know is if, at any other time in the patient’s life, he has ever experienced a similar situation So you ask, “Have you ever had anything like this before?” (It’s also a good idea to ask how it was treated if the patient has had a similar complaint in the past.)

So simple, so thorough, just like they taught us in EMT-Basic school, and again in EMT-Intermediate school, and even again in EMT-Paramedic school! So why don’t people use it? Many people say it’s because they can never remember on the spot what the letters in OPQRST stand for. Others say that they prefer not to follow such a rigid approach to getting a history, because not all patients are calling us for pain, and they don’t feel those questions have any significance. Well, just like you always start your car by pressing on the brake first, then turning the ignition key, if you get into the habit of thinking about all the questions the same way every time, you may make the decision to skip some that don’t apply, but you are thinking of all of them, and won’t forget any important ones.

Once you know about the symptoms that caused the patient to call you, you can then obtain the rest of the SAMPLE history. Allergies -- pretty straightforward. Be sure to ask about natural rubber latex and food reactions as well. (Did you know that there’s a link between allergies to latex and reactions to kiwi, avocado, and banana? I have had a number of patients who are unaware of that connection, but who have had these food sensitivities. This is a good time not only for us to know for ourselves and our care that this patient might be sensitive to latex, but also to educate the patient to this possible connection.)

Ask about Medications -- be sure to include over-the-counter medicines, herbal remedies or dietary supplements. One thing many people also forget to ask is what medicines the patient might have taken for this particular symptom or episode, including over-the-counter medicines such as Tylenol or ibuprofen and herbal remedies, so remember to add that to your litany of questions as well.

Probably the most likely area for EMTs to write only what the patient told them is Past medical history. If there is no past medical history documented on the run sheet, does the patient not have any significant past medical history, did the patient not volunteer any, or did the EMT not ask? If asthma is the only thing written as past medical history, does that indicate that asthma is the patient’s only medical history, or is that only the only history the patient volunteered?

I have developed a mnemonic I use to help me ask about past medical history, so, again, I’m not depending on the patient to randomly volunteer what he or she thinks is significant. Using the familiar ABCs, and adding a D and an E, it allows me to ask about every serious medical condition I’m likely to need to know about. I think first about airway and breathing as a combined unit, and ask the patient, “Do you have any Asthma or Breathing problems like COPD, emphysema, or tuberculosis? Do you smoke?” The answers to these questions not only give me information about past medical history but they help me assess for pertinent risk factors and determine what kind of response the patient might have to oxygen administration. From there, I move on to the letter C, which reminds me to ask if he has any cardiac or circulatory problems as well as cancers: “Do you have any heart problems, blood pressure problems, circulation problems, stroke or TIA history, or have you had any cancers?” And, D and E, “How about Diabetes, or Epilepsy, or any other medical problems?” (See Figure 1.) I finish off by asking if the patient has ever had any operations. There are few things more embarrassing than writing that you suspect your patient with abdominal pain has appendicitis then finding out when you get to the hospital that he had his appendix removed twenty years before.

Figure 1

I’m always amazed when I take over care of a patient who has nothing, or even just one or two things listed in the history as obtained by the previous provider, and when I ask my ABCDE history I uncover several other serious medical conditions that the patient hadn’t thought to volunteer, and the previous provider hadn’t asked specifically for. ABCDE takes only a few seconds, and you end up with a comprehensive history.

The other benefit of this approach is that it helps those patients with a long and detailed history (who are often all too willing to share every detail of that history) keep the focus on what information you especially need at this very moment. It is a very effective way of eliminating all the extraneous information from your less focused patients.

So, so far we have gotten the OPQRST of the patient’s symptoms, his allergies, medications, and the ABCDEs of his medical history. All that’s left in the SAMPLE history is Last oral intake and Events leading to the call for help. Make sure when you ask about oral intake, that you don’t just ask when the patient ate last, but rather you ask when the last time was that he had anything at all to eat or drink. And as for Events, with everything you’ve already asked, you already know what led up to the call for help. I actually use Events as a trigger to summarize for the patient what information he’s given me about why he called, in order to make sure I have it right.

In terms of subjective information, that pretty much covers it all. Of course, now the goal is to write it down, and, because you used such an orderly system to obtain it, writing it down is a snap. You simply recreate the exact same story on the run sheet, and except for putting the allergies and medications in their own separate boxes (absolutely no need to write them in the narrative if you put them in their boxes), you write it exactly as you obtained it. Just remind yourself of what you asked, in the same order, (See Figure 2.) and you can write down symptoms first, beginning with onset, provoking/palliating factors, quality, radiation, severity scale, and time; then allergies and medications; past medical history; and last oral intake.

Figure 2

A systematic, orderly approach to asking your patients questions will help you obtain the information you need in the most efficient manner. And once you get the information you need, the system will help you document that information in a way that most efficiently conveys it.

© 2003 by Jacqueline B. Vaniotis