Transcript Documentation

DOCUMENTATION
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Takes, or verbalizes, body substance isolation precautions
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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
 Determines the mechanism of injury/nature of illness
Nature of illness determined to be shortness of breath
 Determines the number of patients
Advised of one patient
 Considers stabilization of spine
At this time there is no obvious indication of injury
 Requests additional help if necessary
 ALS requested as well as additional manpower
ALS 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, nonlabored respirations with full chest expansion noted.
 Assesses circulation
 Assesses/controls major bleeding
No obvious injury or bleeding noted
 Assesses pulse
Pulse normal, strong and normal
 Assesses skin (color, temperature and condition) skin w/d/p
 Identifies priority patients/makes transport decision
Determined to be a priority patent and will intercept with ALS.
With assistance stood a pivoted onto cot. Placed in M500
 FOCUSED HISTORY AND PHYSICAL
EXAMINATION/RAPID TRAUMA ASSESSMENT
 Signs and symptoms (Assess history of present illness)
Hx. of C/C: O P Q R S T
SAMPLE
PMHx. of COPD.
 Performs focused physical examination (assesses affected body
part/system or, if indicated, completes rapid assessment)
This is what we have been doing all along
Baseline VS: B/P 138/74
RR 18
HR 88
 Interventions (obtains medical direction or verbalizes
standing order for medication interventions
 and verbalizes proper additional intervention/treatment)
All interventions as recorded
Transport (re-evaluates the transport decision)
Departed scene to intercept with ALS as documented
 Detailed 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
 UEs: Neg. peripheral edema
 ONGOING ASSESSMENT
 Repeats initial assessment
Airway remains patent with no change in respiratory rhythm and
quality
*Repeats vital signs
 Repeats focused assessment regarding patient complaint or injuries
 States she feels she is breathing better with the O2 and doesn’t feel
as short of breath
 XX:XX intercepted with and released to M500 with changes in
condition as recorded.