DOCUMENTATION Takes, or verbalizes, body substance isolation precautions Determines the scene is safe Dispatched to the above location for shortness of.

DOCUMENTATION

• Takes, or verbalizes, body substance

isolation precautions

• Determines the scene is safe

Dispatched to the above location for shortness

of breath

Upon arrival no obvious or apparent signs of an

unsafe scene noted

D

etermines the mechanism of injury/nature of illness

Nature of

illness determined to be shortness of breath

D

etermines the number of patients

Advised

of one patient

C

onsiders stabilization of spine

At this

time there is no obvious indication of injury

R

equests additional help if necessary

A

LS requested as well as additional manpower

A

LS requested and advised of a 12 min. ETA. Additional

manpower also requested and advised of a 7 min. ETA ..

INITIAL ASSESSMENT

General Impression, Determines chief

complaint/apparent life threats

XX:XX Presented to an ill 68 yowf, with C/C of

shortness of breath with no apparent life

threats noted sitting in recliner in living room.

Assess Airway and Breathing

Initiates appropriate oxygen therapy

Adm. O2 at 15 LPM via NRB

Assures adequate ventilation, Assesses airway and

breathing

Airway patent with and uncompromised with quiet, non-

rapid, non-labored respirations with full chest expansion

noted.

A

ssesses circulation

A

ssesses/controls major bleeding

No

obvious injury or bleeding noted

A

ssesses pulse

Pulse

normal, strong and normal

A

ssesses skin (color, temperature and condition) skin w/d/p

I

dentifies priority patients/makes transport decision

D

etermined to be a priority patent and will intercept with

ALS.

W

ith assistance stood a pivoted onto cot. Placed in M500

F

OCUSED HISTORY AND PHYSICAL

EXAMINATION/RAPID TRAUMA ASSESSMENT

S

igns and symptoms (Assess history of present illness)

H

x. of C/C: O P Q R S T

S

A M P L E

P

MHx. of COPD.

P

erforms focused physical examination (assesses affected body part/system or, if

indicated, completes rapid assessment)

Th

is is what we have been doing all along

Ba

seline VS: B/P 138/74 RR 18 HR 88

I

nterventions (obtains medical direction or verbalizes standing order for medication interventions

a

nd verbalizes proper additional intervention/treatment)

All

interventions as recorded

Tr

ansport (re-evaluates the transport decision)

De

parted scene to intercept with ALS as documented

D

etailed PE:

Face:

Neg. cyanosis or facial edema

Neck:

Neg. tracheal deviation

Chest: As

recorded

ABD:

Neg. Distension; soft and non-tender

LEs:

Neg. LE or pedal edema

U

Es: Neg. peripheral edema

O

NGOING ASSESSMENT

R

epeats initial assessment

A

irway remains patent with no change in respiratory rhythm and quality

*

Repeats vital signs

R

epeats focused assessment regarding patient complaint or

injuries

S

tates she feels she is breathing better with the O2 and doesn’t

feel as short of breath

X

X:XX intercepted with and released to M500 with changes in

condition as recorded.