A (Arrival) - Arrived on scene to find a ______. Patient greeted EMS appropriately. No acute life threats.
C (Chief Complaint) -
H (History) -
HPI:
Pertinent Negatives: Patient denies having any other medical complaints. Patient denies feeling pain or being injured anywhere else. Patient denies shortness of breath, chest pain, headache, nausea, vomiting, any vision disturbances (double vision, loss of vision). Patient denies hitting their head, having any pain in their head, or being on blood thinners. Patient denies feeling sick.
Medical History:
A (Assessment) -
Mental status: A&Ox4 (patient is able to correctly answer who the president is, their location, the current year, and the events leading up to EMS arrival), GCS 15, FAST negative, VAN negative.
Life threats: Airway open and patent. Breathing regular rate, nonlabored with no accessory muscle use or retractions, patient is able to speak in full sentences with ease. Skin well perfused, warm, dry.
Head: HEENT normocephalic exam. No DCAP-BTLS noted to head. No drainage from eyes, ears, nose, or mouth, Face is symmetrical with no drooping. Pupils PERRL.
Neck: No DCAP-BTLS noted to neck. No JVD and no tracheal deviation. No pain upon palpation of C-spine and no stepoffs noted, no new neurodeficits noted to any part of body, no significant distracting injuries present, no reported previous c-spine surgeries or known spinal disease, and patient was GCS 15. No nuchal rigidity.
Chest: No DCAP-BTLS noted to chest. Symmetrical chest rise and fall. Patient denies shortness of breath and chest pain.
Arms: No DCAP-BTLS noted to arms and shoulders. PMS present in both arms.
Abdomen: No DCAP-BTLS noted to abdomen. Abdomen soft and non-tender with no distension. Negative Grey Turner sign and negative Cullen's Sign.
Pelvis: No DCAP-BTLS noted to pelvis. Pelvis stable.
Legs: No DCAP-BTLS noted to legs or feet. PMS present in both legs. Patient's gait was normal / stumbling.
Vitals:
12-lead ECG interpreted by Paramedic ____ as ____.
12-lead ECG machine interpretation was _____.
Capnography waveform was ___ and capnography values were within normal limits for patient.
Rx (Treatment) - Patient was placed on a stretcher, secured to the stretcher with all three seatbelts, wheeled to the ambulance, and loaded into the ambulance without incident. Vitals and a 12-lead ECG were obtained on the patient, a history was obtained from the patient, and the patient was further assessed.
T (Transport) - Vitals were reobtained at regular intervals throughout transport and remained stable. Patient's ___ increased / decreased. Did interventions improve patient's condition and how did they?
D (Destination) - Patient was transported BLS non-emergency / emergency to ______. Patient's destination was determined by ________. Patient was transferred to ______ in ED without incident and patient care was turned over to RN in ED.