This is an example on how to write a good run report:
Run Report Clarification: This is to help everyone be on the same page
of what we need in each and every run report.
1. Chief Complaint (main issue): Example- Chest
pain, abdominal pain, Suicide attempt, weakness, etc.
This can be any main complaint that they had during their visit, stay,
hospitalization. For example they were admitted for sepsis and are now going to
the nursing home. Their chief complaint can still be sepsis because this is WHY
they were at the facility. Avoid “doctor’s office visit” or “dialysis” as chief
complaint. It's best to have 3 complaints/concerns/diagnosis etc. It needs to follow the ICD-10 guidelines.
2. Secondary complaint (any other complaints). Please never put n/a, etc. This is any
complaint that they have had during their visit/exam/hospitalization/etc. This
includes any complaints even if they are not currently experiencing
that complaint. For example: nausea, vomiting, weakness, confusion, etc. Feel
free to put patient did have nausea but resolved after hospital gave Zofran.
3. Somewhere in the report we need to have a diagnosis. As EMS we can't
diagnosis but 90% of our runs are hospital to hospital transports and they
doctor has put down a diagnosis. You can also put down "Rule out..."
For example. "Diagnosed with Appendicitis" or "Rule out
4. Needs a reason why they can't stay where they
are at. Examples: Needs stat cardiology consult not available at Morrow County
Hospital. Needs discharged to nursing facility for continued long term medical
care and rehab. Needs admitted to a psychiatric facility for mental evaluation
5. Needs a "H&P"
History and physical is the most important information you can provide.
HISTORY: Discuss the events that occurred before, during and
after the event or transport. Use your "OPQRST" that you
learned in school: Onset (started?), Provoke/Palliative
(what makes it worse/better), Quality (how bad? what does it feel like?),
Region and Radiate (where is it at/does it go anywhere?), Severity (how bad was
it at it's worse and what is it now?), Time (what were you doing when it
started, when did this occur).
Document Pertinent negatives.
Physical/Assessment: Each run must have an assessment that includes how the patient looks,
acts and how they are doing/feeling. It needs to be more than "Patient
moved to the cot, straps x 3, report given." That is not a complete
assessment. Please feel free to add this but please add their skin color (pale,
pink, bruised), respirations (labored, normal), neuro assessment (alert to
person, place and time), general assessment/how do they look (appears toxic and
weak). Abdominal exam, cardiac exam, Etc. Document any abnormal findings.
Remember if it wasn't documented... then it wasn't done!
*Document any abnormal labs, CT, ultrasounds, x-rays, tests.
*Report medications given, IV's, Cardiac monitor, NG tubes, feeding tubes, etc
prior to arrival and during transport.
*Document any special needs (needs to remain flat due to decub ulcers on the
buttocks)/ splints (requires bilateral leg padding and splinting due to
pressure wounds, need to elevate legs due to a DVT)/ any special requirements
(needs isolation precautions due to staph infection).
*It is also important to
document any pertinent patient medical
*Please always put this in your report: "Patient requires
continuous medical supervision in route." If they didn't need
medical supervision, then they didn't need you.
Interventions: Always document any meds/procedures/events that occurred during transport.
Document any changes in the patient. Anything you assessed or did
during transport. Even if it’s just changing their position in route. That
shows that you provided medical attention.
"Wrap up statement." How did the run go? What
happened? Turned over to? Report? Anything else needed said?
Vitals: Per Life Line
protocol document vital signs a MINIMUIM every 20 minutes during transport.
AND AS ALWAYS: AVOID ABREVIATIONS!
Run report Example:
Chief Complaint: Shortness of
breath, fever, cough
Secondary Complaint: Weakness, Chest pain
Diagnosis: Pneumonia, Generalized weakness, Rule out sepsis
History and Physical: This is an 84
year old female that came to the ER on 3/5/2017 with a complaint of shortness
of breath and cough. Symptoms started last night but got worse this morning.
Family had to call 911 at noon because she was too weak to walk. Patient also
complained of fatigue and generalized body aches. Movement makes the symptoms
worse. Nothing made the symptoms better. Shortness of breath was severe at
home. In the ER, X-rays show right lower lobe pneumonia. She was found to have
a fever of 102 and was given Tylenol. Her WBC was elevated at 20 and the doctor
is concerned she might be septic. She was given 1 gram of Rocephine IV. She is
now going to Marion General for a higher level of care and pulmonary consult
not available at Morrow County. Patient also found to be hypoxic with a pulse
ox of 89% on room air. Patient placed on oxygen via nasal cannula by ER staff.
Patient did have some mild chest pain that was a 2/10 but it has resolved. Pain
was dull and radiated to the back. Patient has a history of congestive heart
failure and diabetes. Patient denies any
lower leg swelling, left arm pain, jaw pain or dizziness. First set of cardiac enzymes are negative.
Assessment: Weak appearing
female that is pale found in room 2a. Patient moved to cot x 3. Straps x 3.
Patient requires continuous medical supervision in route. Patient found on
oxygen via nasal cannula at 2 liters per minute. Pulse ox has improved to 94%.
Patient has a harsh wet cough. Fever is down to 100 after Tylenol. IV is
infusing well via pump at 125 cc per hour. Antibiotics completed in route. No signs of
allergic reaction. Patient has a 20 g IV to the left wrist without signs of
infiltration. Lungs fields show some mild wheezing in the bases. Blood pressure
is stable. Cardiac monitor shows a sinus tachycardia at 110 beats per minute.
No ST segment changes. Patient is flushed to the face. Family to follow the
squad. Patient is alert to person, place and time. Vitals monitored every 15
minutes. Report given to Medical staff.
Patient turned over to room 140 without incident. No nausea at this time.
15:30 Patient continued to have wheezing and cough. Patient complains of more
severe shortness of breath and having 1/10 chest pain on the left. Dull pain.
Albuterol 2.5mg nebulized given x 1. Improvement of wheezing noted. Less cough.
Heart rate increased to 115. Patient states she felt it helped. IV infusing
well via pump. Blood pressure stable. Monitor continues to show a Sinus Tachycardia.
Pain continues to be a 1/10.
Ok. That's a lot of info. Lets get this in a nutshell. What do I need to document?
1. Chief complaint: Diagnosis or rule out, plus 2-3 complaints/concerns
2. Secondary complaint: What else is going on
3. Why can't they say where they are (need ortho, cardio, surgery, long term rehab?).
4. History and physical (a MINIMUM of a PARAGRAPH EACH). History: Discuss OPQRS!!! What meds were given? Labs? CT? X-ray? IV's? Cardiac Monitor? Drips? Interventions? Nursing report?
Physical- Assessment of neuro, cardiac, skin, respiratory, IV sites, cardiac monitor interpretation, response to treatment, etc. How do they look? Act? On oxygen? Foley cath/drains/tubes?
5. Patient needs medical supervision in route because...
6. Anything you did, interventions, medications given, etc.
7. Wrap up statement
8. Vitals (minimum of every 20 min).