Fort Sill EMS

DISPATCH:
On [date name="date"] Fort Sill EMS unit [select value="161|171|172|231"] was called [select value="emergency status|non-emergency status"] to [select value="above location|TMC (troop medical center)|UC (urgent care)"] for [text] [select value="year old|month old|unknown age|"] [select value="male|female|unknown gender patient|multiple patients"] with complaints of [text] per dispatch. EMS response made by myself and paramedic [select value="David Gregorin|Whitney Red Elk|John Monroe|Theo Rogers|James Reed|Ana Homan|Alex Garland|Michael Bolin|Dalton Berger"], during [select value="nighttime|dusk|dawn|daytime"] hours with [select value="clear weather|rain|snow|high winds"] and [select value="normal|wet|icey"] road conditions[select value=". No delays in en route time or response time.| causing slight delay in response.| causing significant delay in response."] FSFD [select value="was|was not"] dispatched on this call.

[checkbox value="ADDITIONAL INFORMATION GIVEN DURING RESPONSE:
While en route to scene dispatch advised"] [textarea]

ARRIVAL:
Upon arrival found above patient, approximately [text] pounds, [textarea] [checkbox value="ambulatory,"] [checkbox value="awake and alert,"] [checkbox value="with no obvious bleeding or other life threats noted."]

Consent:
[select value="Expressed consent given by patient prier to treatment.|Expressed consent given by caregiver prier to treatment.|Implied consent used in this situation due to patients condition."]
Information regarding procedures and findings relayed to patient during examination and treatment to assure informed consent.
[text]

CHIEF COMPLAINT:
[select value="Patient|Caregiver|Bystander|Provider|Fort Sill police department (FSPD)|Fort Sill Fire department    (FSFD)|Drill Sergeant"] states [textarea]

HISTORY:
Past Medical History:
[textarea]

History of Present Illness:
[textarea]

Allergies:
[textarea]

Medications:
[textarea]

ASSESSMENT:
On Scene Primary:

Mentality:
[select value="Awake, alert, orented, to person, place, time, and event with a glascow coma score of 15.|Altered.|Confused.|Responsive to verbal.|Responsive to pain.|Unresponsive."]
[text]

Airway:
[select value="Patent airway, maintained by patient, with no current concern of compromise.|Partially obstructed airway.|Occluded airway."]
[text]

Breathing:
[select value="Adequate breathing.|Inadequate breathing.|Absent breathing."]
[text]

Circulation:
[select value="Adequate circulatory status.|Compromised circulatory status.|Inadequate circulatory status."]
[text]

Patient placed in [select value="semi-fowlers|supine|sitting"] position onto EMS cot and secured via raised rails and seat belts X5 for patient safety. Patient and cot loaded into EMS unit and cot secured via floor locking mechanism.

DETAILED ASSESSMENT:
Initiated prier to departure and continued en route.

PSYCH:
[checkbox value="Patient denies recent or current suicidal or homicidal ideations. Patient denies recent or current visual and/or auditory disturbances or hallucinations."]
[text]

SKIN:
[checkbox value="No bleeding, bruising, or trauma noted. Skin is pink, warm, and dry, with appropriate turgor. No complaints of rashes, or itching. No significant findings."]
[text]

Head Ears Eyes Nose Throat:
[checkbox value="No bleeding or trauma noted. Pupils equal round and reactive to light. Open airway, appropriate and adequate breathing. No jugular vein distention noted, no tracheal deviation, no carotid bruits noted. Patient denies vision or hearing problems. No discharge or drainage from ears or nose. No significant findings."]
[text]

CHEST:
[checkbox value="No bleeding or trauma noted. Lung sounds clear and equal to auscultation in upper and lower bilateral fields. Normal heart sounds. No significant findings."]
[text]

ABDOMAN:
[checkbox value="No bleeding or trauma noted. Non-tender in four quads with no rebound tenderness, no distention noted. Bowel sounds present upon auscultation. No significant findings."]
[text]

PELVIC:
[checkbox value="No bleeding or trauma noted. No significant findings."]
[checkbox value="Last menstrual period"] [text]
[text]

UPPER EXTREMITIES:
[checkbox value="No bleeding or trauma noted. Circulatory, motor, and sensory equal and present. Appropriate capillary refill, No significant findings."]
[text]

LOWER EXTREMITIES:
[checkbox value="No bleeding or trauma noted. Circulatory, motor, and sensory equal and present. No significant findings."]
[text]

BACK:
[checkbox value="No bleeding or trauma noted. Lung sounds clear and equal to auscultation in upper and lower bilateral fields. No significant findings."]
[text]

INITIAL VITAL SIGNS:
Blood pressure [text]/[text]. Pulse [text]. Respiratory rate [text]. SpO2sat [text]%. FSBS [text]mg/dl. EKG [text]. ETCo2 [text] mm/Hg. Pulse index [text]%. SpCO [text]%. SpMet [text]%. 
[checkbox value="Pleth waveform evenly spaced, equally wide waves of equal amplitude."]
[text]

VITAL SIGNS UPON ARRIVAL AT DESTINATION:
Blood pressure [text]/[text]. Pulse [text]. Resppiratory rate [text]. SpO2sat [text]%. EKG [text]. ETCo2 [text]mm/Hg. Pulse index [text]%. SpCO [text]%. SpMet [text]%. 
[checkbox value="Pleth waveform evenly spaced, equally wide waves of equal amplitude."]
[text]

TREATMENTS:
[checkbox value="Adult assessment|Pediatric assessment|IV established|IV fluids given|12-lead EKG|15-lead EKG|Posterior EKG|Continuous EKG monitoring|Medication(s) given|Blood Glucose Check|ETCo2 monitoring|Oxygen|Bleeding control|Splinting|CPAP"]
[text]

EXPLINATION AND RESPONSE TO TREATMENT(S):
[textarea]
 
Decision for [select value="non-emergency|emergency"] transport made by primary medic and decision for use of [select value="Comanche County Memorial Hospital|Southwestern Medical Center"] ER [select value="per patient request|per care giver request|per drill sergeant request|per provider request|due to closest appropriate facility"] with primary medic agreeing with appropriateness of this receiving facility.

DURING TRANSPORT [textarea]
[checkbox value="vital signs and primary assessment repeated without significant changes."]
[checkbox value="Patient transported without complications."]
[checkbox value="Radio report made to receiving facility en route with acknowledgment made by facility."]

Upon arrival at ER report given to [select value="nurse|provider|ER staff"] [text] and personal belongings given to [select value="Patient|nurse|battle buddy"].

Patient assisted safely into bed in room [text]. Nursing staff in room assuming care prier to termination of EMS care.

[checkbox value="EXCEPTIONS:"]
[textarea]

Ryan J Dial

________________________
NREMT-P