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Scenario #: (Name of Scenario)

Page: Please respond to (location) for (dispatch).

Scene: Basic overview of scene.

Patient #: (Name or description of patient)

Check/Time 0:00 04:00 08:00

Airway Clear/Other Clear/Other Clear/Other

C-Spine Clear/Other Clear/Other Clear

Breathing Present/Absent Present/Absent Present/Absent

Circulation Present/Absent Present/Absent Present/Absent

Primary Survey: (Relevant findings found on primary survey. Include all major injuries,
abnormalities, etc.)

S:
A:
M:
P:
L:
E:

Set 1 (00:00) Set 2 (04:00) Set 3 (08:00)

LOC A&O / GCS / AVPU A&O / GCS / AVPU A&O / GCS / AVPU

HR Rate/rhythm/quality Rate/rhythm/quality Rate/rhythm/quality

RR Rate/rhythm/quality Rate/rhythm/quality Rate/rhythm/quality

BP Systolic/diastolic Systolic/diastolic Systolic/diastolic

Pupils PERL/other (size)mm PERL/other (size)mm PERL/other (size)mm

Skin Colour/temperature/quality Colour/temperature/quality Colour/temperature/quality

spO2 (number)% (room (number)% (room (number)% (room


air/oxygen) air/oxygen) air/oxygen)

BGL (number) (number) (number)

Temp (number)C (number)C (number)C


Treatment:
 Recommended and required treatments
 Transport requirements
 After-care recommendations

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