EMS Reporting

Initial/Response:
 Rescue 1 was dispatched to “______________” for “age sex chief
complaint” Upon arrival Patient was where? What position? Who was
on scene (police, bystanders)? Unconscious? Where the patient is?
Patient’s complaints
 Patient complains of what? Symptoms?
 Pain… Pain level. How long have they been in pain… Radiates
 Patient denies general pain, CP, N/V/D, loss of consciousness, syncope,
and visual disturbances. Patient denies hx of taking anticoagulants. Pt
denies drug/ETOH use.
Evaluation
 Patient is A&O x3.
 HEENT: Normocephalic/atraumatic, Pupils PERL, Face symmetrical.
 NECK: Trachea midline, No JVD.
 CHEST: Clavicle and chest wall intact, positive symmetrical rise and fall,
LS clear in all fields.
 ABD: Soft non tender (S/NT).
 Pelvis: Stable, intact.
 BACK: No obvious signs of trauma or injury.
 EXT: Positive csm x 4 w/strong peripheral pulses, moves all extremities
appropriately, negative edema. Patient skin warm and dry.
 Patient’s vitals and blood sugar are within normal limits.
  If need be you can put: Rest of secondary assessment unremarkable.
Plan
 How was the patient treated? Patient was given an ice pack. Patient had
a Cervical collar placed.
Transport
 Patient transferred stair chair x 2 straps then transferred to stretcher x5
straps x2 side rails into rescue one. Monitored vitals en route, no
change. Pt transported without incident. Patient delivered and accepted
by ER staff. Patient care report given to receiving RN.