Date: Chief complaint

Dispatch:

Enroute: Presumptive Diagnosis/Protocol Used:

Arrive Scene: Allergies None U/k

Depart Scene:

Arrive Dest.:

PATIENT INFORMATION

MEDS NONE

U/K

MEDICAL HISTORY None U/K Allergies Asthma COPD Nicotine User HTN Cardiac CHF CVA Communicable Disease Behavioral Disorder Cancer Diabetes Epilepsy Other AGE SEX RACE HISTORY OF PRESENT ILLNESS/INJURY

PARAMEDIC ASSESSMENT

LOC CHOOSE ONLY ONE Alert/Oriented Responds to Voice Responds to Pain Unresponsive WEIGHT _________________ lbs. KG

PRIMARY SURVEY Normal Partial Obst. Total Obst.

PUPILS PERTL Other R ____________ L ____________

TEMP Normal Warm Cool Cold Hot COLOR Normal Pale Flushed Mottled Cyanotic SKIN Time P

VS (AT SCENE) R BP Sa02

GLUCOSE _____Time____ _____Time____ _____Time____

Normal Labored Rapid Shallow Absent Normal Weak Bounding Irregular Absent

CERVICAL SPINE Pain Numbness Tenderness Motor Loss N/A

BODY CHART

PAIN SCALE (10 = worse): SKIN TURGOR TEST RESULT:

Normal Wet/Diaph. WHERE:

TEMP (Thermometer): WNL NEURO CVA SCALE HEAD NECK CHEST LUNGS ABDOMEN BACK/SPINE PELVIS EXTREMITIES N/A ABN Edema PROCEDURES O2 _______ LPM Cannula Mask Bandage Bleeding Control Burn Care BVM Ventilate C-Spine Control Cardiovert Chest Decompress Chest Seal CPR Defib X #_____ Extricate/Vehicle Extricate/Confined Space Foreign Body Removal Intubate Irrigation IV Start KED EKG Monitor Med Given Paced Position/Shock Restraints Splint/Extremities Suction Traction Splint BSI 12 Lead EKG Other: __________________ __________________ __________________ AIRWAY TYPE/PROCEDURE Head Tilt Jaw Thrust NPA OPA Combitube RSI Other N/A ET INTUBATION Nasotrach Orotrach Equal B/S Cord Visual Confirmed by Device ______ Unable N/A # Attempts:_______ INIT:__________ Time Solution IV THERAPY Gauge Site Rate/Amt INIT Clear - Equal/Bilateral Wheezes Rhonci Rales Crackles JVD TD PHYSICAL EXAM (COMMENTS) Weakness Location: Facial Droop Slurred Speech Arm Drift Decr. Sensation Location:

TREATMENT

CHANGES ENROUTE

MEDICAL CONTROL CONTACT: YES ORDERS: TIME TREATMENT/RESPONSE INIT TIME

No Unable to Contact

Time:_____________ INIT

TREATMENT/RESPONSE

TIME

EKG READING

Rate

INIT Time Eye: Verbal: Motor: Total:

GLASGOW COMA SCALE

TRAUMA SCORE Time: GCS: Resp. Sys. BP

DESTINATION:

PATIENT LEFT AT: Hosp. ED Hosp. Bed Hosp CCU Triage Outpatient Dept. Residence

Other Medical Facility NA

Other:________________________________________

STATS

PREVENTIVE AID None Seatbelt / Harness Airbag / Belt Airbag Only Child Restraint Protective Helmet Padding / Protective Clothes Other INJURY SEVERITY Possibly Severe Non-Incapacitating Incapacitating

INJURY TYPE Burn Fracture Lacerate/Penetrate Internal Drown/Suffocate/Choke Drug Overdose Acute Alcohol Intox. Spine/Brain Scrape/Bruise/Cut Sprain/Strain

AID PRIOR TO ARRIVAL None Yes/CPR Only Yes/CPR+AED/Time to AED:_________ Yes/AED Only/Time to AED:_________ Yes/Other WITNESSED ARREST Yes No N/A ARREST TO CPR 0-4 4-6 6-10 >10 AID BY Family First Resp Police Other

VEHICLE DAMGE Steering Wheel Deformed Major Damage to Exterior Major Damage to Interior Rollover Windshield Spiderweb Intrusion to Interior DAS/Same Vehicle Extrication Required

UPON ARRIVE PATIENT Ambulatory Recliner/Chair Wheelchair

FOUND IN: Bed Gurney/Table Other_____________

PATIENT LEFT AT END-POINT OF TRANSFER: Ambulating Bed Specialized Wheelchair Bed/Chair Gurney/Table Recliner Other:_____________ BED CONFINEMENT: Unable to get out of bed without assistance Unable to sit upright Unable to ambulate without assistance

ADDITIONAL NARRATIVE/ECG STRIPS:

Best Motor Response 1 2 3 4 5 6 No Response Extension Flexion-abnormal Flexion-withdrawal Localizes Pain Obeys

Best Verbal Response 1 2 3 4 5 No Response Incomprehehnsible sounds Inappropriate words Disoriented and converses Oriented and converses

Eyes Response 1 2 3 4 No response To pain To Verbal Command Spontaneously

Glasgow Coma Scale (Add all of the above):______________________________________

Glasgow Coma Scale 0 1 2 3 4 0-3 4-5 6-8 9-12 13-15

Respiratory Rate 0 1 2 3 4 0 1-5 6-9 - >29 10-29

Systolic Blood Pressure 0 1 2 3 4 0 1-49 50-75 76-89 >89

Trauma Score (Add all the above):_________________

STUDENT SIGNATURE

PERSONNEL (Circle One) Driver_________________ ____ EMT EMT-I EMT-P

TDH COURSE NUMBER

Sem (F/S/Int)

STUDENTS

PRECEPTOR SIGNATURE

Attendant__________________ EMT Student____________________ EMT

EMT-I EMT-P EMT-I EMT-P

EMS SITE: ETMC-Tyler Other

EMS UNIT