Axon Education requires students to use the DCHARTI format for documentation. Students who are accustomed to other charting methods will need to adapt to this requirement when writing narratives during clinical/field and capstone internships.

Example

D - Dispatch Information

1. What did dispatch tell you over the radio?
2. What mode are you being dispatched (i.e emergent or non-emergent)?
3. Did you respond lights and sirens?

C/C: Chief Complaint

1. What did the patient say is the problem? Use quotes if you can!
2. "My chest hurts."
3. "I can't feel my leg."

History (Hx):

1. Who is on scene when you arrive?
2. Patient's Family
3. Fire Department
4. Police Department, etc.
5. Who called EMS?
6. Patient
7. Bystander
8. Law enforcement, etc.
9. What is your general impression of the patient?
10. How did you find the patient?
11. Are they in distress? What body position are they in?
12. Were they walking around yelling?, etc.
13. Speak to the patient and ask them why they called EMS.
14. Many patients have a long list of medical history and chronic pain. They will say that they've been in pain for weeks or months, so as a provider, you need to know what is significant about TODAY! Why did they see it necessary to call EMS today if they've been living with pain for however long?
15. SAMPLE/OPQRST Questions
16. SAMPLE questions belong to the history section of your narrative.
17. OPQRST questions may be divided between the history and assessment sections, depending on how you like to tell the story. As long as it is accurate and makes sense, these deviations are acceptable.
18. Was any care rendered prior to EMS arrival?
19. Does the patient have any pertinent medical history/conditions? Does the patient take any medications?
20. If the answer is "No" to either, you still need to address that in your narrative.
21. Every trauma patient is a medical patient! You will treat them the same with your history - with additional attention paid to the mechanism of injury.
22. What was the trauma?
23. Ask about loss of consciousness, if they hit their head, etc.
24. A fall: Why did they fall? Ask if they fell from a chair, standing position, etc. Ask if they fell face first or if they fell on their back.
25. A car accident: Ask about seat belts worn, airbags deploying, and note any damage to the vehicle. Ask the patient's recollection of the accident, how fast they were going, and note who else was involved if anyone.

Assessment:

1. As a provider, you should ALWAYS do your own assessment and never take the word of another provider. If you are ultimately responsible for this patient, you take the hit if something happens to the patient because you failed to complete your own assessment.
2. AxOx? (person, place, time, and event)
3. GCS (eyes, verbal, motor)
4. Assess all life threats (Mr. 5) and mention each one.
5. Airway, Breathing, Pulse, Skin, External Bleeding (Ask about abnormal bleeding as well)
6. Do a complete physical assessment
7. Lung sounds, heart tones, palpating chest/abdomen (if indicated)
8. CMS/PMS and DCAP-BTLS for all traumas
9. Describe results from any test performed (stroke, concussion, etc.)
10. Initial and Secondary Vital signs (can also be included in the treatment section if preferred)
11. If a patient refuses a physical assessment, you still must complete a visual assessment and it needs to be documented that they refused a physical assessment!

Treatment (Rx):

1. What treatment did you administer to the patient? Include 5 rights!
2. Bandaging
3. Oxygen
4. Medication, etc.
5. Initial and Secondary Vital signs (if not already in the assessment section)
6. Did the patient's condition remain unchanged, improve, or worsen throughout transport?

Transport:

1. How did the patient move from their location to the stretcher?
2. Mention all stretcher straps applied.
3. What facility was the patient taken to?
4. How did the patient move from the stretcher to the hospital bed? What bed?
5. Mention all reports given, whether during transport or at the hospital, or both. Also, document who you handed off patient care to.
6. Mention obtained signatures.
7. If a patient denies transport, you need to explain to the patient your concerns for them if they choose not to go to the hospital. Then, they need to sign a refusal form and you need to document this happening. You should obtain a refusal signature and if they also refuse to sign that, you'll need to get a witness signature from law enforcement (any professional besides your partner if possible) of all their refusals.

Impression(s):

1. This is where you explain your differential diagnoses. What do you, as the provider, think is happening with this patient?
2. If someone calls for abdominal pain, your history and assessment should help you form your opinion of ectopic pregnancy, stomach ache, appendicitis, etc.

Note: Every scene has its own set of challenges. When in doubt, document exactly what you witnessed, what was said, and gain witness signatures from other first responders and your partner.