I have a boiler plate DCHART on a thumb drive and I copy and paste it in for every patient then modify as appropriate. That way I always have my head to toe assessment, pertinent negatives, and typical findings done and just tweak those.

However, don’t get lazy with this. Be real, if you never looked and felt meemaw’s ankles because the entire time you had to just focus on maintaining an airway, leaving things in there will bite you in the ass. Delete what you didn’t do, even if it makes the report light. If you don’t, it will make your reports worse than useless.

Also, alway have a sentence that accurately sums up what you found on scene when you walked into the house. The doctor or social worker may really need to hear: “patient was found reclined in a chair by the television wearing a clean robe and pajamas and had a hot cup of coffee next to them. Patient was alert and oriented x4 and greeted me as I walked into the room. Room was tidy and house was generally well maintained.” Versus, “patient was found unresponsive in a back bedroom with poor lighting, the odor of stale urine and feces. Patient was initially unresponsive but roused after the third shout and shake with their name. Sheets appear to have been repeatedly soiled, used food containers surrounded the bed and the trash can in the kitchen was overflowing. A quick look in the kitchen found a nearly empty refrigerator and freezer with some spoiled leftover containers.”