Interventions for patients with cardiac chest pain need to be rapidly delivered. Many of those interventions — like oxygen and aspirin — are administered as you assess the patient. To ensure complete and helpful documentation for a chest pain patient, use these Tips:
1. Anticipate the information you will need to document as you respond. Review OPQRST before you make contact with the patient.
2. Walk into the call with a pen and paper in hand. Start writing down the patient’s vitals, OPQRST, associated signs, pertinent negatives and SAMPLE as they are reported.
3. Make sure you, your partner or another medical first responder gathers an initial set of vital signs without being interrupted to do other tasks or ask the patient questions.
4. CRITICAL: Remember to ask the patient about recent use of erectile dysfunction drugs, like Sildenafil.
5. Look at your wrist watch every time an intervention is applied. Write down the time and the intervention.
6. Develop a personal system for writing notes that you will later use to complete the ePCR.
7. Don’t forget to reassess and write down vital signs and patient’s pain rating after each intervention.
Still writing patient information on your gloves?
Stop. Use a pen and paper or have a person assigned to document care as it is delivered.
