documentation takes, or verbalizes, body substance isolation precautions determines the scene is...
TRANSCRIPT
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
D
etermines the mechanism of injury/nature of illness
Nature of
illness determined to be shortness of breath
D
etermines the number of patients
Advised
of one patient
C
onsiders stabilization of spine
At this
time there is no obvious indication of injury
R
equests additional help if necessary
A
LS requested as well as additional manpower
A
LS requested and advised of a 12 min. ETA. Additional
manpower also requested and advised of a 7 min. ETA ..
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.
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.
A
ssesses circulation
A
ssesses/controls major bleeding
No
obvious injury or bleeding noted
A
ssesses pulse
Pulse
normal, strong and normal
A
ssesses skin (color, temperature and condition) skin w/d/p
I
dentifies priority patients/makes transport decision
D
etermined to be a priority patent and will intercept with
ALS.
W
ith assistance stood a pivoted onto cot. Placed in M500
F
OCUSED HISTORY AND PHYSICAL
EXAMINATION/RAPID TRAUMA ASSESSMENT
S
igns and symptoms (Assess history of present illness)
H
x. of C/C: O P Q R S T
S
A M P L E
P
MHx. of COPD.
P
erforms focused physical examination (assesses affected body part/system or, if
indicated, completes rapid assessment)
Th
is is what we have been doing all along
Ba
seline VS: B/P 138/74 RR 18 HR 88
I
nterventions (obtains medical direction or verbalizes standing order for medication interventions
a
nd verbalizes proper additional intervention/treatment)
All
interventions as recorded
Tr
ansport (re-evaluates the transport decision)
De
parted scene to intercept with ALS as documented
D
etailed 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
U
Es: Neg. peripheral edema
O
NGOING ASSESSMENT
R
epeats initial assessment
A
irway remains patent with no change in respiratory rhythm and quality
*
Repeats vital signs
R
epeats focused assessment regarding patient complaint or
injuries
S
tates she feels she is breathing better with the O2 and doesn’t
feel as short of breath
X
X:XX intercepted with and released to M500 with changes in
condition as recorded.