EMS CHART

What is an EMS CHART Template?

In many nations like the United States, first responders and emergency medical service (EMS) personnel must complete documentation regarding the patient's initial condition, health status during transportation, and responses to treatment procedures. Failing to complete EMS documentation may not only result in disciplinary action but has been associated with poorer patient outcomes, morbidity, and mortality (Alatis et al., 2020; Short & Goldstein, 2022). Accurate documentation is crucial for legal and medical records, ensuring continuity of care and legal compliance.

An Emergency Medical Services (EMS) Chart Template is a resource used to structure and enhance the quality of EMS narratives or reports following dispatch. The structure organizes this information and breaks down the required details in each section.

Typically, an EMS CHART would include the following information (Medavie Health Ed, n.d.):

• C - Complaint (the patient's chief complaint)
• H - History (previous medical history, medications and allergies)
• A - Assessment (physical examination and vital signs)
• Rx - Treatment (treatment procedures and details in order)
• Tx - Transport (transport and transition details)

The template can be completed electronically or printed, and a physical copy can be completed manually.

How does it work?

The CHART method EMS works by organizing all information in order and providing spaces for personnel to fill in critical patient data. To show you how this works, we have broken down the template process into the following steps:

Step 1: Access the template

You can access the template online to obtain a digital copy or download a printable PDF version if you prefer to complete it manually. There is also a column for EMS details where you may note patient demographics.  

Step 2: Document the chief complaint

When you collect data, start with the chief complaint, which refers to the reason for the EMS callout. This section can include the patient's chief complaint alongside information from initial assessments that contextualize the situation. 

Step 3: Record the patient's medical history 

If the patient's circumstances allow it, record past medical history, medications administered, and other information regarding the patient's condition. This will update the patient's records and may help determine causality.

Step 4: Document thorough assessment details

List the patient assessment procedures completed during EMS care and the results or findings from these. This may include physical examinations, recording blood pressure as part of the vital signs, and signs of injuries.

Step 5: Record treatment details 

Record the pre-hospital treatments or procedures conducted. These may include procedures taken before dispatch arrival, such as CPR or Epipen administration, and those born once EMS arrived and during transport. In this section, be precise about the equipment used, steps taken, personnel involved, and other details necessary for the treatment. 

Step 6: Document transport information

Ensure that all transport information is recorded, including where the patient was taken, the equipment used, the procedures and treatments administered, and any changes. Additionally, it is essential to note any patient responses or refusals to treatment or transport procedures. 

Step 7: Review and sign

Review the document critically to add details and check for errors regarding patient's care. Complete the template by signing and dating the document.

EMS CHART example (sample)

We have created an example of how the EMS CHART Template PDF works in practice. The example uses fictitious information about a patient. Healthcare professionals should use this as a reference when completing the EMS report template. However, the information in the example should not substitute patient data or be used as an example of correct procedures during an emergency. 

Download the EMS CHART example PDF here:

When would you use this EMS report template?

Transferring patient information from EMS dispatch to receiving health center professionals is crucial to patient care. This shift depends on efficiently conveying patient specifics, including the caller's health condition, injuries, chief complaint, and background. Situations in which this template may be used include the following: 

EMS callout 

EMS professionals, such as paramedics, may use the template to document the callout procedures and patient care before the health center transitions. This may help keep track of the patient's health status and any changes throughout the emergency that can be used to inform patient care. Furthermore, the template may document important callout information that can be used for financial and legal purposes. 

In health centers

Health centers, such as hospitals or clinics, may use the template to standardize their approaches to emergency documentation. This can ensure that all professionals are on the same page and enhance the quality of EMS documentation. 

Enhancing protocols 

Given the fast-paced nature of these health facilities, emergencies can happen quickly and spontaneously. It is essential to include all details to develop effective strategies and protocols to monitor these events.

Why use Carepatron as your emergency medical services software?

At Carepatron, we aim to provide groundbreaking solutions that improve practitioner and patient experiences. Our technology streamlines administrative tasks such as clinical documentation, appointment scheduling, and medical billing, saving time and resources and allowing practitioners to dedicate more time to patient care.

Being an online platform, Carepatron provides continuous access to resources such as this template, facilitating the seamless transition of patient care from EMS personnel to emergency department physicians. This ensures that all necessary information about patient care and health status is available for well-informed procedures. 

Embark on the journey to enhance your practice and elevate patient care with Carepatron today!

References

Alatis, A. S., Monahan, M. B. V., Raymond, M. A. D., Hudson, M. K. B., MD, Vieth, C.-S. J. T., Nable, Mbc. J. V., MD, & NRP. (2020, February 25). Checklists improve EMS documentation. The Journal of Collegiate Emergency Medical Services. https://www.collegeems.com/checklists-improve-ems-documentation/

Medavie Health Ed. (n.d.). Section 9 PCR documentation guidelines. https://www.medaviehealthed.com/wp-content/uploads/2017/11/Section9PCRDocumentationGuidelinesMedavieHealthEd2014.pdf

Short, M., & Goldstein, S. (2022). EMS documentation. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448107/

Montgomery County MD. (n.d.). CHART documentation [Handout]. https://www.montgomerycountymd.gov/mcfrs-psta/Resources/Files/ems/emt-class-resources/CHART-handout.pdf