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Documentation

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Pt info given en route: male in 304A complaining of chest pain, SOB. ... He reported a sudden onset of substernal chest pain and SOB, so he laid down and ... – PowerPoint PPT presentation

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Title: Documentation


1
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2
The Wide Wide World of Documentation
  • Ursinus College SERV
  • Mike Roberts, EMT-B

3
Data Taken on Scene
  • Chief Complaint
  • LOC or Mental Status
  • SAMPLE History
  • Vital Signs
  • Personal Info

4
Chief Complaint
  • O
  • P
  • Q
  • R
  • S
  • T

5
Chief Complaint
  • Onset
  • Provoking Factors
  • Quality
  • Radiation
  • Severity
  • Time

6
LOC / Mental Status
  • CAOx4
  • ALS / Transport!!!

7
SAMPLE History
  • Signs / Symptoms
  • Allergies
  • Medications
  • Past Medical History
  • Last oral intake
  • Events leading up to incident

8
Vital Signs
  • Pulse, Respirations, Blood Pressure
  • Baseline Vitals taken immediately
  • Compare
  • Stable Pt every 15 minutes
  • Unstable Pt every 5 minutes

9
Personal Info
  • Name
  • Address
  • Home/college
  • Phone Number
  • Home/college
  • Social Security Number

10
Additional Info
  • Location
  • Times
  • From Safety Desk
  • Responding Units / Personnel
  • Other notes
  • Scene survey, general impressions

11
If Pt is Transported
  • Copy all info taken on scene for the ambulance
  • Take note of
  • Transport Unit
  • Transport Times
  • Destination
  • Emergency / Non-emergency

12
Time to Write the PCR
  • EMStat
  • Narrative
  • Dispatch
  • Scene Survey
  • Treatments
  • CC
  • HPI Events leading up to
  • PE Complete even on medical pts
  • PMHx

13
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.

14
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

15
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.

16
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

17
GO HOME!!!
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