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Documentation

Documentation

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Documentation

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  1. Documentation Takes, or verbalizes, body substance isolation precautions 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

  2. 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

  3. 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 ..

  4. 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.

  5. 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, non-labored respirations with full chest expansion noted.

  6. 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

  7. 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

  8. 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

  9. S A M P L E 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

  10. 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

  11. 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

  12. UEs: Neg. peripheral edema • ONGOING ASSESSMENT • Repeats initial assessment Airway remains patent with no change in respiratory rhythm and quality *Repeats vital signs

  13. 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.