Writing a protocol

A patient protocol is where you document one patient’s care from first contact to handover. This page walks through filling one in, tab by tab. It is written for operators — the Sanitäter at the tablet.

A protocol lives inside a Dienst (event). For how protocols are opened, listed, and closed within a Dienst, see Dienst lifecycle.

Protocols are usually written after the fact. In the field you take notes on a glove or a scrap of paper; the protocol is transcribed later — sometimes much later, sometimes by someone who was not on scene. Every tab is built for this: timestamps are editable, data sets are sparse (fill only what you have), and clinical readings are repeatable snapshots you can add out of order. Nothing forces you to enter data live or in sequence. Enter what actually happened, at the time it happened, whenever you sit down to write it up.

The 7-tab shell

A protocol opens as a shell with a sidebar on the left and one panel per tab. The tabs are, in order:

  1. Rettungsdaten — patient and mission data

  2. Anamnese — history and first assessment

  3. Vitalzeichen — vital-sign snapshots

  4. Scores — clinical scores

  5. Maßnahmen — interventions and material

  6. Diagnose — working diagnosis

  7. Übergabe — handover (closes the protocol)

Each sidebar entry shows a per-tab completion state — not started, in progress, or complete — so you can see at a glance what still needs attention. You can move between tabs freely and in any order; there is no forced wizard until the very end, at Übergabe.

You do not have to fill every tab. A protocol for a minor complaint may only ever have Rettungsdaten, a short Anamnese, and an Übergabe. Complete the tabs that apply to the patient in front of you.

Rettungsdaten

The first tab captures who the patient is and the frame of the mission.

  • Patient and personal data — name, date of birth, and the other identifying fields.

  • Times — the mission timestamps. These are editable: when you transcribe after the fact, set them to the real times from your notes rather than "now".

  • Location — capture the position by GPS or enter an address. The captured standort prints on the finished protocol.

  • ID — the patient / case identifier.

  • "angelegt" toggle — marks the protocol as formally created.

Because this tab sets the times and identity everything else hangs off, it is the natural place to start — but you can come back and correct any field at any point before the protocol is closed.

Anamnese

The Anamnese tab records the patient history and first assessment, structured along the ABCDE scheme (Airway, Breathing, Circulation, Disability, Exposure). Work through each section with what you observed.

Alongside the structured fields is a free-text Erstbefund (first assessment). To speed up transcription, the Erstbefund has a snippet catalog: pick a pre-written phrase and it is inserted at the cursor so you can assemble a description quickly instead of typing every finding from scratch. Insert a snippet, then edit the surrounding text as needed.

Vitalzeichen

Vital signs are recorded as repeatable snapshots — each snapshot is one set of readings at one point in time. A patient may have several: on arrival, after a Maßnahme, at handover.

  • Enter values with the numeric keypad.

  • Record pain with the pain scale — the Wong-Baker faces scale, tapped rather than typed.

  • Each snapshot carries its own timestamp, which you can set to the real time of the reading.

Past snapshots collect in the Verlauf drawer (see The Verlauf drawer), which shows a trend chart across the snapshots. Tap any row to edit that snapshot — correct a value or fix a time after the fact.

Scores

The Scores tab holds clinical scores, each computed from the values you enter and each saved as a timestamped, editable snapshot. Supported scores include:

  • NEWS2 — National Early Warning Score 2

  • ABCDE — structured across its sections

  • GCS — Glasgow Coma Scale

plus sectioned, per-location, and binary score variants. When you save a score, a recommendation banner summarises what the score implies. Like vital signs, scores are repeatable — take a fresh score whenever the patient’s state changes — and they share the same Verlauf drawer for history and editing.

Maßnahmen

The Maßnahmen tab is where you log interventions and the material they consumed, per protocol. It presents a "streamdeck" — a grid of tiles, one per Maßnahme or item.

  • Flagless tiles are logged with one tap.

  • Richer tiles open a modal with a variant picker and an amount stepper, so you can record which variant and how many.

The tiles themselves are driven by an admin-curated catalog. What appears on the grid, and which tiles are simple versus modal, is configured centrally — see Material catalog.

Some material is consumed here that also counts against the Dienst’s overall stock. A consumes-link pushes that consumption up into the Dienst material tally automatically, so an item logged on a protocol is not double-counted against the Dienst.

Diagnose

The Diagnose tab records the working diagnosis — your clinical impression for this patient. Keep it to what you are actually documenting; it feeds the handover and the printed protocol.

Übergabe

Übergabe is a guided handover wizard, and it is the tab that closes the protocol. Work through it:

  1. Pick the handover type — who you are handing the patient to.

  2. Capture SBAR where it helps — Situation, Background, Assessment, Recommendation.

  3. Collect signatures on the signature pad. Colleague signatures are roster-driven (pick the person from the Dienst roster); other signatures — free-text names, or the patient — are entered directly.

Completing the Übergabe closes the protocol. A closed protocol is the finished record. Make sure the other tabs say what you mean before you finish the handover — a closed protocol is what gets printed and archived. See Printing a protocol.

The Verlauf drawer

Vitalzeichen, Scores, and Maßnahmen share one pattern for history and correction: the Verlauf drawer. It lists every snapshot you have recorded on that tab, newest changes visible at a glance, and — for vital signs and scores — draws a trend chart across them.

Tap any row to open and edit it. Because the whole app assumes after-the-fact authoring, this is how you correct a mistyped value or set a snapshot to its real time long after the moment passed. Nothing about a snapshot is locked while the protocol is open.

See also