Documentation

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(No Transcript)
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The Wide Wide World of Documentation

• Ursinus College SERV
• Mike Roberts, EMT-B

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Data Taken on Scene

• Chief Complaint
• LOC or Mental Status
• SAMPLE History
• Vital Signs
• Personal Info

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Chief Complaint

• O
• P
• Q
• R
• S
• T

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Chief Complaint

• Onset
• Provoking Factors
• Quality
• Radiation
• Severity
• Time

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LOC / Mental Status

• CAOx4
• ALS / Transport!!!

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SAMPLE History

• Signs / Symptoms
• Allergies
• Medications
• Past Medical History
• Last oral intake
• Events leading up to incident

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Vital Signs

• Pulse, Respirations, Blood Pressure
• Baseline Vitals taken immediately
• Compare
• Stable Pt every 15 minutes
• Unstable Pt every 5 minutes

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Personal Info

• Name
• Address
• Home/college
• Phone Number
• Home/college
• Social Security Number

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Additional Info

• Location
• Times
• From Safety Desk
• Responding Units / Personnel
• Other notes
• Scene survey, general impressions

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If Pt is Transported

• Copy all info taken on scene for the ambulance
• Take note of
• Transport Unit
• Transport Times
• Destination
• Emergency / Non-emergency

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Time to Write the PCR

• EMStat
• Narrative
• Dispatch
• Scene Survey
• Treatments
• CC
• HPI Events leading up to
• PE Complete even on medical pts
• PMHx

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Example Narrative

• SERV dispatched to Riemert 304A via campus
  safety for an ill male. Pt info given en route
  male in 304A complaining of chest pain, SOB.
• Upon arrival, pt found laying in bed. Pt
  reported he was writing a feminist lit paper and
  began feeling nauseous. He reported a sudden
  onset of substernal chest pain and SOB, so he
  laid down and called SERV. Vitals taken, found
  to be stable. Pt reported the pain began at
  approx 2120 and has been a 8 on a 10 scale every
  since (approx 30 mins). He reported the pain to
  be substernal, radiating to his left arm. He
  described the pain as a crushing sensation. He
  reported the pain slightly reduced if he laid
  down. He reported he has never experienced this
  pain before.

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Narrative (cont)

• Pt placed on 15 lpm O2 via NRB. 911 contacted.
  Pt monitored prior to ALS arrival. Upon arrival,
  ALS assisted. Pt assisted to litter and
  transported to ambulance. Pt transported via
  ambulance 324 to Pheonixville Hospital
  non-emergency.
• CC chest pain, SOB
• HPI No prior history, Substernal pain with left
  arm radiation steady for approx 30 mins, 8 on a
  10.
• PMHx asthma

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Narrative (cont)

• PE Pt was CAOx4, skin warm and diaphoretic.
  HEENT unremarkable. Chest atraumatic, pain
  non-sens to palp. Abd soft/non-tender.
  Priapism noted. Extremities unremarkable, full
  PMS.

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Legal Junk

• 24 HOURS!!!!!!!!
• Two printouts
• File (with refusal) / Wellness box
• SIGN BOTH
• May be subpoenaed
• All treatments/observations/decisions must be
  accurate and concise

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GO HOME!!!