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PALM BEACH STATE COLLEGE EMT/Paramedic Program PATIENT CARE REPORT Student: _________________________ EMT Time of Call: _______________ Paramedic Date: ____/____/_____ Hospital/Agency: ____________ Unit: ____________ □ I accompanied this patient to the hospital during transport. Patient Age:___ Instructor Name: _________________ ETHNICITY M F Instructor Signature: ______________________ Chief MEDICAL COMPLAINT Abdominal Cardiac CVA Diabetic OB/GYN African American American Indian Asian Caucasian Hispanic Chief TRAUMA COMPLAINT OD-Poison Psychiatric Respiratory Seizure Sepsis Abdomen Chest Extrem. Muscular Neck/Back Pelvic Head/Face Multi-system Other ___________________ Other ___________________ Other: ___________________ MECHANISM OF INJURY None Driver MVA Passenger MVA Airbag Seatbelt Entrapment Penetrating Injury – Type: _____________________ Auto-Pedestrian Motorcycle Fall/Jump Ejection Rollover Blunt Other: ______________________________________ ALLERGIES: MEDICATIONS: PAST MEDICAL HX: Time BP Eyes Open→ Verbal→ Motor→ Pulse Resp Spontaneous 4 Orient 5 Obey Com. 6 AVPU GCS To Voice 3 Confused 4 Pain/Local 5 Lungs To Pain 2 Inappropriate 3 Pain/Withdraw 4 BLS AIRWAY NC NRB Nasal airway ALS AIRWAY Surgical Nasal ET Oral ET Pulse Ox on room air ________ IV / IO Attempts X: _____ ELECTRICAL THERAPY MANUAL DEFIBRILLATION SYNCHRONIZED CARDIOVERSION TRANSCUTANEOUS PACING ENERGY LEVELS Success: OBS. Drug/Tx None 1 Garbled 2 Pain/Flexion 3 % After O2 ________ Y N None 1 Pain/Ext 2 Oral airway Attempts X: ____ Site: ________ Rhythm 1: Rhythm 2: Rhythm 3: BVM Success Y N Route None 1 @ ______L/Min ET size: ___ % Glucometer __________ Gauge: ______ EKG INTERPRETATION PERF. Dose Solution: ______ OBS PERF TRAUMA CARE BLS CARE OBS PERF OBS PERF PATIENT INTERVIEW WITNESSED ARREST VITAL SIGNS SUCTION 02 ADMINISTRATION CHEST COMPRESSIONS BANDAGING VENTILATIONS TRACTION SPLINT BLS airway adjunct C-SPINE AIRWAY ADJUNCT TYPE: IMMOBILIZATION ALS CARE – OTHER LONG BACKBOARD DESCRIBE LONG BONE IMOBILIZATION STUDENT PHYSICALLY INVOLVED IN LIFTING PATIENT YES NO CHEST DECOMPRESSION CRICOTHYROIDOTOMY 12 LEAD ECG PULSE OXIMETRY BLOOD GLUCOSE CHIEF COMPLAINT: S O A P Field Impression: # PERFORMED Obs Per
