Station 5 PCR

DISPATCH:
On [date name="date"] Lawton [select value="E5|L5|R5"] was dispatched [select value="emergency status|non-emergency status"] to [select value="above location"] for [text] y/o [select value="male|female"] with complaints of [text] per dispatch.  [select value="Kirk's EMS|CCMH-EMS|Reynolds EMS"] was also dispatched on this call.
ARRIVAL:
Upon arrival [textarea]

CHIEF COMPLAINT:
[select value="PT|Caregiver|Bystander|Provider"] states [textarea]

HISTORY:
PMH: [textarea]
HPI: [textarea]
Allergies: [textarea]
Medications: [textarea]

ASSESSMENT:
Primary:

Mentality
[checkbox value="AAOx4|GCS 15|Altered|Confused|Responsive to verbal|Responsive to pain|Unresponsive"]
[text]

Airway
[checkbox value="Patent airway|Partially obstructed airway|Occluded airway"]
[text]

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

Circulation
[checkbox value="Adequate circulatory status|Compromised circulatory status|Inadequate circulatory status "]
[text]

Detailed:

Skin:
[checkbox value="No bleeding, brusing, or trauma noted, PWD, appropriate turgor, no complaints of rashes, or itching, no significant findings"]
[text]

HEENT:
[checkbox value="No bleeding or trauma noted, PERRL, open airway, appropriate and adequate breathing, no JVD noted, no tracheal deviation, no carotid bruits noted, no vision or hearing problems, no discharge or drainage from ears or nose, no significant findings"]
[text]

Chest:
[checkbox value="No bleeding or trauma noted, LSCTAx4, equal and bilateral breath sounds, normal heart sounds, no significant findings"]
[text]

Abdomen:
[checkbox value="No bleeding or trauma noted, non-tender X 4 quads, no distention noted, bowel sounds present, no significant findings"]
[text]

Pelvic:
[checkbox value="No bleeding or trauma noted, no significant findings"]
[text]

Upper extremities:
[checkbox value="No bleeding or trauma noted, CMS equal and present, appropriate capillary refill, no significant findings"]
[text]

Lower extremities:
[checkbox value="No bleeding or trauma noted, CMS equal and present, no significant findings"]
[text]

Back:
[checkbox value="No bleeding or trauma noted, LSCTAx4, equal and bilateral breath sounds, no significant findings"]
[text]

Initial Vitals:
Blood pressure [text]/[text]. Pulse [text]. Resp rate [text]. O2sat [text]%. FSBS [text]mg/dl. EKG [text]. ETCo2 [text] mm/Hg.

Second set of vitals:
Blood pressure [text]/[text]. Pulse [text]. Resp rate [text]. O2sat [text]%. EKG [text]. ETCo2 [text]mm/Hg.

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"]
[text]

Explanation and Response to treatment(s):
[textarea]

Upon arrival of  [select value="Kirk's EMS|CCMH-EMS|Reynolds EMS"]report given to care transferred at this time.

Pt placed in semi-fowlers position and secured to cot via raised rails and safety belts X3 for safety.

 
Patinet transported [select value="non-emergency|emergency"] status made by primary medic to [select value="CCMH|SWMC"] ER.



Exceptions:
[textarea]

Matt McKinney

________________________
AEMT #55126