D (Dispatch) -
A (Arrival) -
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, GCS 15.
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.
Neck: No DCAP-BTLS noted to neck. No JVD and no tracheal deviation.
Chest: No DCAP-BTLS noted to chest. Symmetrical chest rise and fall. Lung sounds clear bilaterally.
Arms: No DCAP-BTLS noted to arms and shoulders.
Abdomen: No DCAP-BTLS noted to abdomen. Negative Grey-Turner's and Cullen's sign.
Pelvis: No DCAP-BTLS noted to pelvis.
Legs: No DCAP-BTLS noted to legs or feet. Patient's gait was normal.
Vitals:
12-lead ECG interpreted by Paramedic Ethan Coe as ____.
Capnography waveform was ___ and capnography values were within normal limits for patient.
Rx (Treatment) -
T (Transport) - Vitals were reobtained at regular intervals throughout transport and remained stable. Patient remained stable and in no apparent distress during transport.
D (Destination) - Patient was transported ALS 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.
Ethan Coe NRP