Assessment: GENERAL: [textarea name="appearance" default=" Interacting with EMS appropriately; well appearing; not acutely distressed. "] CNS: [textarea name="CNS" default=" Speech is not slurred; CMS grossly intact in all 4 extremities; gait is steady. "] PSYCH: [textarea name="psych" default=" No reported recent or active suicidality or homicidal ideations. No reported recent or active visual/auditory disturbances. "] CARDIOVASCULAR: [textarea name="cardiovascular" default=" No immediate concerns. Equal radial pulses bilaterally. "] PULMONARY: [textarea name="PULM" default=" No initial immediate concerns. Normal and adequate tidal volume and respiratory drive. "] GI/GU: [textarea name="GIGU" default=" No nausea or vomiting. No changes in bowel reported. No changes in urine reported. "] HEAD: [textarea name="head" default=" No noted pain or trauma. Pupils equally round/reactive at 4mm in size. No facial droop. "] NECK: [textarea name="NECK" default=" No noted pain or trauma. No JVD. No midline pain. "] CHEST: [textarea name="chest" default=" No noted pain or trauma. Equal rise and fall. Breath sounds CTA bilaterally. "] BACK: [textarea name="back" default=" No noted pain or trauma. "] ABDOMEN: [textarea name="abd" default=" No noted pain or trauma. Soft, flat, non-tender. "] PELVIS: [textarea name="pelvis" default=" No noted pain or trauma. Stable. "] EXTREMITIES: [textarea name="extremities" default=" No noted pain or trauma. No clubbing, cyanosis or edema. "] SKIN: [textarea name="skin" default=" Normal tone, warm, dry. "] VITALS: [textarea name="vitals" default=" "] EKG: [textarea name="ekg" default=" "]
TRANSPORT: [textarea name="TPU" default=" Transport non-emergent to HOSPITAL with pre-arrival notification made enroute. During transport patient remains stable."]
HOSPITAL ARRIVAL: [textarea name="hosp" default=" Upon arrival at ED handoff given to nurse and provider at bedside. Nurse signs PCR. Patient signs PCR. "]
No further care.
- [checkbox name="Student" value="*Some assessments and procedures were performed by paramedic student who was under my direct supervision as the attending paramedic, and consistent with student's scope of practice.*"]