dr-exmedic.com

Over my EMS career, I’ve only had extensive experience with 2 tripsheet programs.  One was programmed poorly and quite buggy; the other was clearly designed for flight nurses, not ground paramedics.  However, both of them would at least produce a report that would give useful data to someone reading it.

In PA, electronic documentation is the law, and few places in this side of the state use handheld computing to any degree, so it’s rare to get a tripsheet on a patient while they’re still in the ED.  Nevertheless, I’ve occasionally referred to EMS documentation on my floor rotations, so tripsheets aren’t entirely worthless–unless they look like this:

Looking down, some of it looks fairly intuitive–when area A is assessed as “Patent” and B gets “Normal Respirations,” this starts to look like the standard ABCs–until you get to C, which get the remark “Neuro Intact.”  And what, pray tell, is area U?  Granted, it’s pretty easy to figure out that this is a basically benign exam (although I seem to remember a bruise or abrasion on this gentleman’s face; it’s tough to tell without my admission H&P in front of me as I admitted him at the beginning of April), but if there were an abnormality, would it be obvious where it was to the casual reader?

I understand that at trial, or back at the station, there’s a key that you can pull out to put these things together.  But to those of us without the magic decoder ring, it’s a total mystery.   How this program meets Pennsylvania standards, I’ll never know.

(Incidentally, I hit the offending agency’s website to let them know that their current program is horrible, but they don’t list an email address or have a comment submission form on their website.)