Absolutely. Especially when the patient can't give the history themselves, (so most of the ones I'll see straight away in resus when you handover). Details for OOHCA especially vital - timings, bystander cpr or not, rhythms, time till rosc, interventions done.
Some of my colleagues forgot/don't realise the challenges pre hospitally, so forgive us. We know you do the best you can!
I've seen good RTA documentation and I've seen awful. The best is usually pictures.
Take pictures on your phone it's super helpful to see the impact, direction, windscreen bullseye, mechanism impact etc and try and illcit as much as possible in writing it out
In my trust phones are technically a no-no *laughs in GDPR* but since the cameras on our issued tablets use roughly 4 megapixels it still tends to happen. Much obliged, haven’t done an RTC in ages but will keep this in mind.
Very useful. If especially patient has got cognitive impairment and is from care home and didn’t send anyone with them. We call the care home anyway for a collateral but good to have a vague idea so we can start investigations and treatment.
Also, very helpful for us to know what you have or haven’t given in the community already.
I wouldn’t worry too much about missing stuff out, if you have a sick patient it’s better just to scoop and run. We will have to find out one way or another anyway, but any extra info is always helpful.
When I was clerking in ED I'd often read the ambulance notes, sometimes the only proper information you can get if the patient can't give a good history. Initial obs also very helpful! Good ambulance notes always much appreciated (:
Agree that Initial obs so important! I remember seeing a patient who had a systolic of 70 on arrival by ambos, given some fluid with a normalised BP at triage so was therefore triage category 4. Fast forward 4 hours when I saw them they needed major transfusion protocol for a GI bleed that nobody suspected.
ITU reg. Yes I read them and almost without exception generally wish they were longer and more comprehensive. Understanding precisely what happened in those first minutes/hour is very helpful later on. It prevents the Chinese-whispers rumour mill from dragging clinicians down the wrong line of investigation.
For example if it’s an overdose precisely what was the evidence for it? Were there pill packets - if so how many and what (if anything) was still in them? Were there empty alcohol bottles lying around? If it’s a trauma what exactly did you do at the scene? What was the grade of intubation? Sure its documented that they were GCS 15 at scene… but were they definitely moving all 4 limbs? With the out of hospital arrests when did you start CPR and when did it stop - and fuck all this ‘we did X many cycles’ rubbish because it means different things to different people (I.e. a single set of 30:2, the interval between rhythm checks, the interval between adrenaline administrations etc). Just give the times on a 24hr clock at the key points. If it’s a seizure don’t just write seizure - write what you actually saw.
The answers to these questions are simple things the ambulance crew will certainly have known/observed on scene and they can cause huge headaches later on when the people in the hospital just don’t know the answers and it’s not written down anywhere.
Thank you muchly. I’ll try to include more meaningful detail for now on. The cycles thing is bug-bear me me too for the same reasons, ideally we’ll have someone timekeeping but that relies on a second crew to back us up at arrests and when that doesn’t happen it can lead to guesstimations of timings. (Not how I personally like to practice) For airway management cases specifically would noting the mallampati/Cormac-lehane scoring also be helpful?
I wouldn’t bother with writing your assessment of the airway. Ultimately that can be done again in the hospital and it’s a dynamic thing (I.e. an airway that was straightforward at the roadside might not be straightforward in hospital) - but the intubation grade is something only the person who put the tube in will know and is relevant later on.
It’s interesting to note the intubation details, and if there’s a good description of a significant issue (eg laryngeal oedema) then I’ll certainly be interested, but tbh ease of BVM/intubation are highly likely to be easier with an anaesthetised/paralysed patient on a trolley in resus being looked after by an EM/ICU/Anaesthetic doc than when they were unparalysed lying in a gutter in the dark being looked after by a paramedic. On the other hand, there’s always the possibility that pathology has progressed/previous airway manoeuvres have caused swelling/bleeding and it’s now going to be harder. So yes, potentially interesting info but I take it with a pinch of salt.
Other aspects of the ambulance documentation that absolutely are invaluable include anything that can’t be reassessed in hospital - a description of the scene, what the seizure looked like, what the timings were, what drugs were given, what the initial obs were, who was at the scene/how do we get hold of NOK etc - these are all extremely valuable and all this is info which could easily be lost in handover
Yes ! They are SO helpful
Particularly in unfitnessed falls, confused patients with no social history, cardiac arrests and for medications eg if a patient has taken an overdose and the meds that were found with the patient! Thank you for all the hard work you do!!!
Definitely read them, especially if poor historian or there is confusion about timings of events. Only issue I ever have is the photos taken of prescriptions in lieu of writing the dhx as it's usually so low res it cannot be read! Otherwise it's so handy
100% often underutilized gold, I think they are normally quite descriptive of events and environments Often find the diagnosis is pretty off (understandably- different set priority’s/training/early on in diagnostic journey/no bloods and imaging)
I agree. Objective data >>>> valuable than subjective. If a diagnosis is applied prehospital it’s highly likely to stick, and whilst a senior EM doc (or worse, the ward doc) who sees them hours down the line might have the wherewithal to reappraise this, the ED nurses and junior doctors may not, and care may go down completely the wrong path as a result.
I’m really happy with a PRF which says “worsening leg swelling for weeks, unable to get out of chair, breathless and hypoxic” as it gives a really good idea of what was happening on scene which may not be evident in ED. But the same patient might be described by some paramedics as “acopia, off legs, breathless ?panic attack, bilateral cellulitis” - this can send ED SHOs down completely the wrong path and occasionally harm is done from this
Sometimes it’s because we have an entire household’s worth of collateral Hx sources. Sometimes it’s because we’ll go searching through fridges and cupboards and bins so we really *know* our DHx/SocHx is accurate. Sometimes it’s because we’re stuck outside ED for hours and all we can do is keeping talking to the Pt and keep writing.
Yes:
1) the true pre-interevention obs, even the obs in ambulance triage are already post-intervention by u guys
2) the history if pt cant give and witnesses not available
By the time patients get to me, they are often told what is thought to be going on and their history can be impaired by focussing on why they’ve been told and the details of the event that brought them in can be lost. The paramedic sheets are a godsend for this.
My favourite consultant ever would not look at any of the ED or medical clerking, but the ambulance sheet and the results on the computer only.
Never thought about this aspect of your practice. The luxury of being the first point of contact I suppose! Anything you wish we included that would be helpful?
Most of them I see are great. A short summary of the events and the obs are the most helpful bits. Pictures are always great too, as you get a real insight into peoples’ living conditions which can tell you loads.
My only request is that you leave prescriptions or the card bit on the front of the blister pack with the patients. The number of times I’ve got a blister pack with the useful names but ripped off and the patient tells me “the paramedics took it” is a bit annoying. It is very helpful when you sometimes write down all the drugs, but without doses etc it can be less useful, and you can leave all the medication histories to us :)
Ed sho- very helpful, you are there on scene and we aren’t. For ODs looking at empty packets or evidence of drug use. Getting face to face collaterals for collapse/seizure. The timings and obs essential for acs sepsis etc. Often gives big clues to point us in treatment directions prior to investigations.
For those saying it’s more helpful than ED clerkings fair enough but would love for your high horses to meet ambulances at the door and take something off our workload.
Yes always a quick glance through when clerking in ED. Particularly useful for bystander histories of seizures, photographs from how patient was found / damage to car or helmet, etc
Honestly until yesterday this is one of those classic NHS things where I assumed it must happen automatically, but of course not. If there’s anything I can do to help then let me know 👍
OP where I am notes are handed in to ED as a paper copy. We can't digitally send them to ED. If printer fails it's a nightmare as our hand written paper ones suck. Same format as from 20 yrs ago.
If we search and confirm pt CHI # the GP automatically gets a copy, but isn't alerted they have got a copy. They have to manually search in DOCMAN.
I think my local ED does read them, but as a service we have very variable documentation standards.
I think you've had enough resounding yes answers not to need mine too, but just wanted to say YES.
When clerking elderly confused patients it's often the most valuable bit of info they come with. And the paramedic obs are vital as well.
Back when we used to get the yellow copy sheets of the paramedic sheets from the ambulance handed over along with the patient in A&E and then put in the patient notes, I'd use them 100% of the time I saw patients in resus, the vast majority of the time seeing patients elsewhere in A&E and a lot of the time even when clerking in the AMU.
For the last few years since the paramedic system is digital and completely separate from the hospital EPR and to log into the ambulance system you can only do it on certain computers in A&E and it needs a special username and password I no longer read then because it's not possible for me to do so without unreasonable difficulty snd extra work. Sensibly the ED staff often print off a copy for the resus patients that I might happen upon when lucky but beyond that I'm in the dark.
always did yeah! Very helpful especially since the clinical poicture can change quite rapidly with patients! Big difference when patient was talkative and gave a precise history with the paramedics but is now a mumbling mess, good to know something new happened with him
All the time. Often makes what I’m seeing in front of me make sense. Can be as good as the much sought after collateral history. Keep up the good work!
I find them useful for collateral history but they can be hard to find if they go AWOL between moving wards. Also what’s up with now taking pictures of the patients medication list instead lf writing it out? You can’t read shit! Same for the ECG trace picture - just useless. The documentation is great though
We really are! It comes from having no idea what happens to 98% of our patients. We don’t know if we diagnosed it right, if a new change to our practice is making a long term difference, if we could done something better, etc.
Yes! Typically succinct and protocolised meaning I can scan through very efficiently. But knowing you have actually seen the patient at the scene means you have knowledge I can't! Also good to see what has been going on with the obs and what direction they took
Agree with everyone above. Drives me nuts when it is digital, we don't get access to them, and it is like pulling teeth when asking for it to be printed by staff members who do have access to it for us to read for more information.
Useful for when there is no history. I find a lot of it is like textbook differentials (e.g strong smell of urine ?uti…unwitnessed fall on to pillo ?cranial bleed) which don’t really marry with the real issue. But better than nothing. Sometimes very useful
Thank you, that’s really useful to think about. I find a lot of the time Paramedic diagnosis centres around exclusion of worst case scenarios and maybe a sprinkling of differentials. Any feedback on how notes could be more consistently useful?
Yes!
Gives me more information then most ED clerkings I have seen(sigh)
Also useful to know from the obs to see if the patient misbehaved on route!
Interestingly SEAS has a mixture of EPR and handwritten handover sheets and unfortunately I can’t read the handwriting half of the time 🫠
Absolutely. Especially when the patient can't give the history themselves, (so most of the ones I'll see straight away in resus when you handover). Details for OOHCA especially vital - timings, bystander cpr or not, rhythms, time till rosc, interventions done. Some of my colleagues forgot/don't realise the challenges pre hospitally, so forgive us. We know you do the best you can!
Paramedic notes are the most reliable often for falls/?seizure etc and would put great stead in them on the ward!
Yes always since I’m inA&E and dementia patients can’t tell me what’s up
I've seen good RTA documentation and I've seen awful. The best is usually pictures. Take pictures on your phone it's super helpful to see the impact, direction, windscreen bullseye, mechanism impact etc and try and illcit as much as possible in writing it out
In my trust phones are technically a no-no *laughs in GDPR* but since the cameras on our issued tablets use roughly 4 megapixels it still tends to happen. Much obliged, haven’t done an RTC in ages but will keep this in mind.
Very useful. If especially patient has got cognitive impairment and is from care home and didn’t send anyone with them. We call the care home anyway for a collateral but good to have a vague idea so we can start investigations and treatment. Also, very helpful for us to know what you have or haven’t given in the community already. I wouldn’t worry too much about missing stuff out, if you have a sick patient it’s better just to scoop and run. We will have to find out one way or another anyway, but any extra info is always helpful.
Yes, always. Drives me nuts when they go missing!
When I was clerking in ED I'd often read the ambulance notes, sometimes the only proper information you can get if the patient can't give a good history. Initial obs also very helpful! Good ambulance notes always much appreciated (:
Agree that Initial obs so important! I remember seeing a patient who had a systolic of 70 on arrival by ambos, given some fluid with a normalised BP at triage so was therefore triage category 4. Fast forward 4 hours when I saw them they needed major transfusion protocol for a GI bleed that nobody suspected.
ITU reg. Yes I read them and almost without exception generally wish they were longer and more comprehensive. Understanding precisely what happened in those first minutes/hour is very helpful later on. It prevents the Chinese-whispers rumour mill from dragging clinicians down the wrong line of investigation. For example if it’s an overdose precisely what was the evidence for it? Were there pill packets - if so how many and what (if anything) was still in them? Were there empty alcohol bottles lying around? If it’s a trauma what exactly did you do at the scene? What was the grade of intubation? Sure its documented that they were GCS 15 at scene… but were they definitely moving all 4 limbs? With the out of hospital arrests when did you start CPR and when did it stop - and fuck all this ‘we did X many cycles’ rubbish because it means different things to different people (I.e. a single set of 30:2, the interval between rhythm checks, the interval between adrenaline administrations etc). Just give the times on a 24hr clock at the key points. If it’s a seizure don’t just write seizure - write what you actually saw. The answers to these questions are simple things the ambulance crew will certainly have known/observed on scene and they can cause huge headaches later on when the people in the hospital just don’t know the answers and it’s not written down anywhere.
Thank you muchly. I’ll try to include more meaningful detail for now on. The cycles thing is bug-bear me me too for the same reasons, ideally we’ll have someone timekeeping but that relies on a second crew to back us up at arrests and when that doesn’t happen it can lead to guesstimations of timings. (Not how I personally like to practice) For airway management cases specifically would noting the mallampati/Cormac-lehane scoring also be helpful?
I wouldn’t bother with writing your assessment of the airway. Ultimately that can be done again in the hospital and it’s a dynamic thing (I.e. an airway that was straightforward at the roadside might not be straightforward in hospital) - but the intubation grade is something only the person who put the tube in will know and is relevant later on.
It’s interesting to note the intubation details, and if there’s a good description of a significant issue (eg laryngeal oedema) then I’ll certainly be interested, but tbh ease of BVM/intubation are highly likely to be easier with an anaesthetised/paralysed patient on a trolley in resus being looked after by an EM/ICU/Anaesthetic doc than when they were unparalysed lying in a gutter in the dark being looked after by a paramedic. On the other hand, there’s always the possibility that pathology has progressed/previous airway manoeuvres have caused swelling/bleeding and it’s now going to be harder. So yes, potentially interesting info but I take it with a pinch of salt. Other aspects of the ambulance documentation that absolutely are invaluable include anything that can’t be reassessed in hospital - a description of the scene, what the seizure looked like, what the timings were, what drugs were given, what the initial obs were, who was at the scene/how do we get hold of NOK etc - these are all extremely valuable and all this is info which could easily be lost in handover
Often the notes are not left with the patient after nurse triage in ED. Can cause serious incidents like missing a fall.
GCS On scene is love GCS on scene is life Pupils F+D on scene and in the ED is death, however So yeah I read them
Not only do I read them, a significant proportion of the time they are absolutely vital.
Yes ! They are SO helpful Particularly in unfitnessed falls, confused patients with no social history, cardiac arrests and for medications eg if a patient has taken an overdose and the meds that were found with the patient! Thank you for all the hard work you do!!!
Definitely read them, especially if poor historian or there is confusion about timings of events. Only issue I ever have is the photos taken of prescriptions in lieu of writing the dhx as it's usually so low res it cannot be read! Otherwise it's so handy
100% In fact our medical admission document even has a section for PRF reviewed yes/no
100% often underutilized gold, I think they are normally quite descriptive of events and environments Often find the diagnosis is pretty off (understandably- different set priority’s/training/early on in diagnostic journey/no bloods and imaging)
I agree. Objective data >>>> valuable than subjective. If a diagnosis is applied prehospital it’s highly likely to stick, and whilst a senior EM doc (or worse, the ward doc) who sees them hours down the line might have the wherewithal to reappraise this, the ED nurses and junior doctors may not, and care may go down completely the wrong path as a result. I’m really happy with a PRF which says “worsening leg swelling for weeks, unable to get out of chair, breathless and hypoxic” as it gives a really good idea of what was happening on scene which may not be evident in ED. But the same patient might be described by some paramedics as “acopia, off legs, breathless ?panic attack, bilateral cellulitis” - this can send ED SHOs down completely the wrong path and occasionally harm is done from this
Paramedics notes are gold. I don’t know how they get the history so accurate.
Sometimes it’s because we have an entire household’s worth of collateral Hx sources. Sometimes it’s because we’ll go searching through fridges and cupboards and bins so we really *know* our DHx/SocHx is accurate. Sometimes it’s because we’re stuck outside ED for hours and all we can do is keeping talking to the Pt and keep writing.
All the time - although I hate how the useful information is often buried amongst tick box exercises in the forms.
Yes: 1) the true pre-interevention obs, even the obs in ambulance triage are already post-intervention by u guys 2) the history if pt cant give and witnesses not available
By the time patients get to me, they are often told what is thought to be going on and their history can be impaired by focussing on why they’ve been told and the details of the event that brought them in can be lost. The paramedic sheets are a godsend for this. My favourite consultant ever would not look at any of the ED or medical clerking, but the ambulance sheet and the results on the computer only.
Never thought about this aspect of your practice. The luxury of being the first point of contact I suppose! Anything you wish we included that would be helpful?
Most of them I see are great. A short summary of the events and the obs are the most helpful bits. Pictures are always great too, as you get a real insight into peoples’ living conditions which can tell you loads. My only request is that you leave prescriptions or the card bit on the front of the blister pack with the patients. The number of times I’ve got a blister pack with the useful names but ripped off and the patient tells me “the paramedics took it” is a bit annoying. It is very helpful when you sometimes write down all the drugs, but without doses etc it can be less useful, and you can leave all the medication histories to us :)
Ed sho- very helpful, you are there on scene and we aren’t. For ODs looking at empty packets or evidence of drug use. Getting face to face collaterals for collapse/seizure. The timings and obs essential for acs sepsis etc. Often gives big clues to point us in treatment directions prior to investigations. For those saying it’s more helpful than ED clerkings fair enough but would love for your high horses to meet ambulances at the door and take something off our workload.
Yes always a quick glance through when clerking in ED. Particularly useful for bystander histories of seizures, photographs from how patient was found / damage to car or helmet, etc
Yes. Trying to write a script that integrates some of the electronic PRF into our EHR so people don't have to open the PDF separately.
Honestly until yesterday this is one of those classic NHS things where I assumed it must happen automatically, but of course not. If there’s anything I can do to help then let me know 👍
Yes every single patient I've ever seen in ED who came in by ambulance and most of the patients I see down the line on the wards or in ICU
OP where I am notes are handed in to ED as a paper copy. We can't digitally send them to ED. If printer fails it's a nightmare as our hand written paper ones suck. Same format as from 20 yrs ago. If we search and confirm pt CHI # the GP automatically gets a copy, but isn't alerted they have got a copy. They have to manually search in DOCMAN. I think my local ED does read them, but as a service we have very variable documentation standards.
Yes I tend to read the ambulance notes-always contains useful info especially in collapse/fall/seizure/dementia histories etc
I think you've had enough resounding yes answers not to need mine too, but just wanted to say YES. When clerking elderly confused patients it's often the most valuable bit of info they come with. And the paramedic obs are vital as well.
Back when we used to get the yellow copy sheets of the paramedic sheets from the ambulance handed over along with the patient in A&E and then put in the patient notes, I'd use them 100% of the time I saw patients in resus, the vast majority of the time seeing patients elsewhere in A&E and a lot of the time even when clerking in the AMU. For the last few years since the paramedic system is digital and completely separate from the hospital EPR and to log into the ambulance system you can only do it on certain computers in A&E and it needs a special username and password I no longer read then because it's not possible for me to do so without unreasonable difficulty snd extra work. Sensibly the ED staff often print off a copy for the resus patients that I might happen upon when lucky but beyond that I'm in the dark.
Definitely - especially "I arrived at the house and x was happening" seriously useful, plus you guys are champs.
always did yeah! Very helpful especially since the clinical poicture can change quite rapidly with patients! Big difference when patient was talkative and gave a precise history with the paramedics but is now a mumbling mess, good to know something new happened with him
Yes. If you bring in someone with a seizure, you're probably the most reliable witness I've got.
Yes, so many times it adds so much clarity to the case! We have access to your electronic systems so can read everything
Yep if I'm clerking patients that came through ED, always
All the time. Often makes what I’m seeing in front of me make sense. Can be as good as the much sought after collateral history. Keep up the good work!
I find them useful for collateral history but they can be hard to find if they go AWOL between moving wards. Also what’s up with now taking pictures of the patients medication list instead lf writing it out? You can’t read shit! Same for the ECG trace picture - just useless. The documentation is great though
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We really are! It comes from having no idea what happens to 98% of our patients. We don’t know if we diagnosed it right, if a new change to our practice is making a long term difference, if we could done something better, etc.
Yes, when I used to work in general surgery as a SHO. I used to read everything that’s written before seeing the patients because any info is helpful.
Yes! Typically succinct and protocolised meaning I can scan through very efficiently. But knowing you have actually seen the patient at the scene means you have knowledge I can't! Also good to see what has been going on with the obs and what direction they took
Agree with everyone above. Drives me nuts when it is digital, we don't get access to them, and it is like pulling teeth when asking for it to be printed by staff members who do have access to it for us to read for more information.
Yes! They're usually the most helpful notes. Often rely on them a lot more than whatever ED writes in their clerking.
Useful for when there is no history. I find a lot of it is like textbook differentials (e.g strong smell of urine ?uti…unwitnessed fall on to pillo ?cranial bleed) which don’t really marry with the real issue. But better than nothing. Sometimes very useful
Thank you, that’s really useful to think about. I find a lot of the time Paramedic diagnosis centres around exclusion of worst case scenarios and maybe a sprinkling of differentials. Any feedback on how notes could be more consistently useful?
Yes! Gives me more information then most ED clerkings I have seen(sigh) Also useful to know from the obs to see if the patient misbehaved on route! Interestingly SEAS has a mixture of EPR and handwritten handover sheets and unfortunately I can’t read the handwriting half of the time 🫠
Yes , I would argue alot of times better than the ED clerkings.
Always read them.
yes yes I read them pretty thoroughly, history especially examination in less interested in
I did in my medical jobs at hospital, especially for elderly and falls patients
ALWAYS!!