Location of pain?
Distention?
Tenderness?
Rigidity?
Guarding?
Nausea, vomiting, diarrhea, constipation?
Last bowel movement?
Urinary complaints (pain, color, amount, frequency)?
Surgical scars?
Pulsating masses?
Femoral pulses, when applicable?
Last menstrual period? - if applicable
Vaginal bleeding/discharge? - if applicable
Can the patient speak or forcibly cough?
Is the patient moving air?
Inspiratory stridor?
What caused obstruction?
Duration of obstruction?
“Patient’s breath had the odor that is commonly associated with the consumption of alcoholic beverages.”
Patient admits to drinking? (type, amount, time frame)
Speech? (normal, slurred)
Gait? (normal, ataxic, unwitnessed)
Obvious head/facial injury?
Vomiting, signs of dehydration?
Altered mental status?
BGL?
Cause of reaction?
Dyspnea? Stridor?
Facial/throat edema?
Chest pain?
Rash, itching, redness?
Urticaria (hives)?
Nausea/vomiting?
Dizziness?
Exposure time?
ETOH/substance abuse?
Syncopal episode?
Neuro assessment performed, results?
Obvious head/facial injury?
Other injuries?
BGL?
Usual level of consciousness/GCS?
Nausea/vomiting?
Type of animal?
Location of bite(s)?
Edema at site?
Venomous?
Method of assault?
Presence of injuries? Head injury?
Bleeding? Controlled?
Loss of consciousness? How long?
Dizziness, nausea, vomiting?
Blurred or double vision?
PMS (pulse, motor, sensory) before/after intervention?
Neck/Back pain?
Paresthesia?
ETOH/substance involvement?
Nausea, vomiting, constipation, diarrhea?
Active bleeding? Amount of blood loss?
Blood emesis/stool? How long?
Color of emesis/stool?
Abdominal pain? Location and quality? Distention?
Urinary complaints?
ETOH/substance involvement?
Law enforcement agency initiating?
Law enforcement officer’s name and badge number?
Reason for M1 hold?
ETOH/Substance involvement?
Reason for hospital choice selected?
Restrained?
Method of restraint?
Position of restraint?
Remember paperwork to be submitted to the hospital.
What is the patient’s mood (agitated, anxious, etc.)?
Is the patient cooperative?
Rate of speech?
Are verbal responses appropriate?
Restrained?
Method of restraint?
Position of restraint?
ETOH/Substance involvement?
See M1 hold, if appropriate.
BGL?
Nausea/vomiting?
Med changes and/or compliant?
Describe MOI?
Presence of injuries? If so, description of injuries (see Injury).
Loss of consciousness? How long?
Rider wearing a helmet? Removed by?
PMS (pulse, motor, sensory) before/after assessment intervention?
Neck/back pain?
Paresthesia?
ETOH/Substance involvement?
Voltage/Amperage?
Duration?
Entrance/Exit wounds?
Neck/back pain?
Loss of consciousness?
Paresthesia?
Description/Location of injury?
Cardiac dysrhythmias
Burn source?
Exposure time?
Describe environment? (Confined space, enclosed space, open area, etc.)
Degrees of burn?
BSA (body surface area) involved?
Facial hair singed?
Dyspnea?
ETOH/Substance involvement?
Circumstances at onset?
Describe patient appearance upon arrival?
CPR performed prior to arrival? Who?
Estimated down time?
Method of airway/ventilation?
Time of first shock?
See INTUBATION, if applicable?
Physician authorizing cease of effort, if applicable?
If ROSC achieved:
12-lead interpretation?
Therapeutic hypothermia, if applicable.
Chest pain?
Dyspnea?
Nausea/Vomiting?
Diaphoresis?
Fever?
ECG Rhythm?
12-lead interpretation?
Location of pain?
What relieves the pain?
Lower extremity edema?
Dyspnea? Palpitations? Irregularity?
Nausea/Vomiting? Hiccups?
Diaphoresis? Pallor?
Taken ED meds within 24 hrs?
Taken aspirin/blood thinner within 12 hrs?
12 Lead ECG interpretation? LVH? LBBB? Paced?
STEMI/Cardiac alert time?
Chest pain?
Dyspnea?
Nausea/vomiting?
Lower extremity edema?
JVD?
Diaphoresis?
CPAP applied? Response?
12-lead interpretation?
Document absent vitals and time.
Position of body upon arrival?
Any repositioning of the body?
Estimated down time?
Obvious injury(ies)? Describe.
Dependent lividity?
Rigor mortis?
Person pronouncing death?
Time of death?
Multiple fetuses?
Mucous plug presented?
Membrane rupture? Meconium staining?
Placenta delivered?
Active bleeding?
Amount of vaginal hemorrhage postpartum?
Obvious vaginal/perineal injury?
Time born?
Baby requires separate report
Cord cut? Who?
Nasal/oral suctioning?
Dried thoroughly kept warm?
Muscle tone (activity)?
General appearance (APGAR), taken at 1 and 5 min. after birth?
Last medication taken?
Last meal?
Oral mucosa- dry or moist?
Breath odor?
Nausea, diarrhea, vomit, constipation?
If vomiting, signs of dehydration?
Excessive exertion?
BGL (pre and post treatment)?
Medication compliant and/or change?
Recent illness?
Altered Mental Status?
Nausea and/or vomit? How long?
Last solid food kept down?
Last liquid kept down?
Skin turgor?
Chest pain?
Dyspnea?
Vertigo?
Diarrhea/constipation?
Dark/blooding emesis?
Recent head injury?
12-lead interpretation?
See ABDOMINAL PAIN ,if applicable.
Type of water?
Time submerged?
Water temperature, if known?
Dyspnea?
Nausea/vomit?
Presence of injury?
Neck/back pain?
Paresthesia?
PMS (pulse, motor, sensory) before/after spinal immobilization?
Loss of consciousness?
Ambulate after onset?
ETOH/Substance involvement?
See INTUBATION, if applicable.
MOI?
Material of Surface struck?
Presence of injury?
Loss of consciousness? How long?
Headache? Nausea? Vomiting? Dizziness? Blurred vision?
Current GCS?
Approximate height of fall?
Neck/Back pain? Scale 1-10?
Paresthesia?
PMS (Pulse, motor, sensory) before/after spinal immobilization or splinting?
ETOH?Substance involvement?
See INJURY, if applicable.
Recent injury or obvious wounds?
Temperature?
Nausea, vomiting, diarrhea, constipation? How long?
Headache?
Nuchal rigidity?
Skin turgor?
Recent travel?
Altered mental status?
BGL?
Possible sepsis patient?
Entrance and exit wounds?
If no obvious entrance/exit, are there any presence of other injuries?
Amount of blood loss?
Caliber of weapon?
Range?
Neck/back pain?
Loss of consciousness?
Paresthesia?
Dyspnea?
Sucking chest wound?
PMS (pulse, motor, sensory) before/after assessment assessment and/or intervention?
Trachea midline?
JVD?
ETOH/substance involvement?
Nausea, vomiting, diarrhea?
Fever?
Skin turgor?
Producing cough? Describe.
Nuchal rigidity?
12-lead interpretation?
Recent travel?
Altered mental status?
BGL?
Possible infection?
‘Possible sepsis patient?
Circumstances surrounding hemorrhage?
Presence of injuries?
Loss of consciousness?
Nausea/vomit?
Dark/bloody stool/ekes is?
Amount of blood loss? (Consider amount of dressings soaked through)
ETOH/substance involvement?
Chest pain?
Dyspnea?
Nausea/vomiting?
Headache?
Visual changes?
Altered mental status?
Grip strength/arm drift?
Weakness?
12-lead interpretation?
Medication change and/or compliant?
Approximate ambient air temperature?
Relative humidity?
Time of exposure?
Type of environment?
Hot dry skin?
Temp>105F ?
Neurological distress?
Fluid intake today?
Signs of heat stroke or exhaustion?
Orthostatic vital signs?
Muscle cramps? Fatigue? Perfume seating?
Skin turgor?
Loss of consciousness?
ETOH/substance involvement?
See SEIZURE, if applicable.
Approximate ambient air temperature?
Type of exposure?
<95F, deep frostbite, any other emergency conditions?
Shivering?
Superficial frostbite?
Estimated exposure time?
Loss of consciousness?
ETOH/substance involvement?
Cardiac dysrhythmias?
Type of gas?
Duration of exposure?
Area of exposure? (Enclosed room, etc.)
Heated environment?
Oral mucosa burns?
Singed facial hair?
Shortness of breath?
How did the injury occur?
Description of injury?
Location of injury(is)?
Active bleeding?
GCS?
Obvious head/facial injury?
Neck/back pain?
Paresthesia?
PMS (pulse, motor, sensory) before/after intervention?
If extremity injury:
Distal PMS?
Type of splint applied?
Which side affected (r/L, bilateral)?
Open/closed fracture, if applicable?
Lower extremity injury:
Shortening?
Inward/outward rotation?
ETOH/substance involvement?
Visualize passage of ET tube through vocal cords?
Absence of epigastric sounds?
Lung sounds present?
CO2 detection?
Size of tube placed?
ET tube depth at teeth?
Secured, how?
Who performed?
Number of attempts?
Confirmed ET tube placement outside of ED? Who?
Confirmed ET tube placement inside of ED? Who?
Newly prescribed medications?
Dyspnea?
Facial/throat edema?
Chest pain?
Rash/itching?
Urticaria (hives)?
MOI?
Vehicle vs ________
Location of damage to vehicle
Driver or passenger?
Wearing a helmet upon arrival? If no, who removed?
Describe damage to helmet, if applicable?
Loss of consciousness? How long?
GCS?
Description/location of injury(ies), if applicable? Document what caused the fall.
Obvious head/facial injury?
Active bleeding?
Neck/back pain?
Paresthesia?
PMS (pulse, motor, sensory) before/after spinal immobilization?
If extremity injury:
Was splint applied?
Distal pulses and sensation?
ETOH/substance involvement?
MOI?
Vehicle vs ________
Location of damage to vehicle
Where was the patient seated when the accident occured?
Where was the patient upon arrival?
Restrained? How?
Airbag deployment?
Steering wheel deformed?
Driver/Front seat passenger - windshield starred?
Speed of vehicle g at time of accident?
Loss of consciousness? How long?
GCS?
Obvious head/facial injury?
Neck/back pain?
Description/location of injury(ies), if applicable.
See INJURY, if applicable.
Paresthesia?
PMS (pulse, motor, sensory) before/after spinal immobilization?
ETOH/substance involvement?
MOI?
Where was the patient upon arrival?
Obvious head/facial injury?
Active bleeding?
Loss of consciousness? How long?
GCS?
Description/location of injury(ies), if applicable. Document what caused the fall.
Distal pulses/sensation, if extremity injury?
Neck/back pain? Severity scale 1-10
Paresthesia
PMS (pulse, motor, sensory) before/after spinal immobilization?
ETOH/substance involvement?
What drug/product?
Route of administration?
How much is involved?
When was it taken?
Intent of ingestion?
Vomiting since ingestion?
Shortness of breath?
Loss of consciousness?
Actions to alleviate (prior to EMS arrival)?
ETOH/substance involvement?
Circumstances preceding poison/overdose?
Oral mucosa burns?
Poison control contacted?
See M1 HOLD if applicable.
Gravida? Para? Abortion?
Last menstrual period?
Length of gestation?
Vaginal bleeding with discharge?
Abdominal pain?
Nausea/vomiting?
Edema? (facial and extremities)
Blood pressure normal for patient?
Headache? Visual disturbances?
Medical/obstetrical history?
Amniotic sac ruptured? When? Appearance/smell?
Multiple births? Delivery dates?
Contractions? Duration? Interval?
Urge to move bowels?
Crowning?
Delivery
Multiple fetuses?
Mucous plug presented?
Membrane rupture? Meconium staining?
Placenta delivered?
Active bleeding?
Amount of vaginal hemorrhage postpartum?
Obvious vaginal/perineal injury?
Time born?
APGAR (1 min/.5 min)?
Neonate (requires separate report)
Cord cut? Who?
Nasal/oral suctioning?
Dried thoroughly? Kept warm?
Muscle tone (activity)?
General appearance (APGAR), taken at 1 min and 5 mins after birth?
Vital Signs, age, GCS noted.
Patient alert and oriented x 4.
Absence of drugs or alcohol.
Patient advised to seek care and risk/benefits of care explained?
Psychiatric history?
Suicidal or homicidal ideations?
Refusal signature obtained?
Witness signature obtained?
Narrative documented appropriately?
Dyspnea? How long?
Patient’s position?
ETCO2?
If apneic, method of airway/ventilations prior to arrival?
Supplemental O2 prior to arrival?
Method of airway ventilations en route to hospital?
ETOH/Substance involvement?
See INTUBATION, if applicable.
Dyspnea? How long?
Patient’s position?
Retractions?
Speech fragmentation?
JVD?
Tracheal deviation?
Lower extremity edema?
Chest pain?
Nausea/vomiting?
Recent illness?
ETCO2?
If apneic, method of airway/ventilations prior to arrival?
Supplemental O2 prior to arrival? CPAP?
ETOH/Substance involvement?
12-lead interpretation?
Reason for standby? (Fire, SWAT, football game, etc.)
Releasing authority from standby?
Description of seizure activity?
Duration?
Number of seizures?
Obvious head/facial injury incur as a result?
If extremity injury, was splint applied?
Obvious h/facial injury prior to seizure?
Incontinence? (Urinary/bowel)
Altered mental status?
Blood Glucose level?
Vomiting, signs of dehydration?
ETOH/Substance involvement?
Method of assault?
Presence of injuries?
Loss of consciousness? How long?
PMS (pulse, motor, sensory) before/after assessment/intervention?
Neck or back pain?
Paresthesia?
Has patient changed clothing, voided, showered, etc. since assault?
ETOH/substance involvement?
Law enforcement notified/-on-scene?
Describe wound(s) and location(s)?
Active bleeding? Amount of loss?
Type of weapon?
Loss of consciousness?
Distal pulses- absent or present?
Distal pulses/sensation, if extremity injury?
Neck veins? (Normal, flat, etc.)
Neck/back pain? severity?
Paresthesia?
PMS (pulse, motor, sensory) before/after spinal immobilization?
See INJURY, if applicable.
Dyspnea?
Sucking chest wound?
Trachea midline?
Type of animal?
Allergic reaction?
Venomous?
Nausea/vomiting?
Grip strength and/or arm drift?
Facial droop?
Headache? Describe.
Nausea and/or vomiting?
Ability to phonate?
Ability to swallow?
Hemiplegia?
Patient able to sit upright without assistance?
BGL?
Fever?
“Stroke Alert” time?
Witness and contact information.
Events preceding syncope?
Duration of unconsciousness?
Number of episodes?
Newly prescribed medications?
Last meal?
BGL?
Chest pain?
Vertigo? Postural?
Dark/bloody emesis or stool?
Description/location of injury(ies), when applicable?
Nausea/vomiting?
Dyspnea?
Incontinence?
Grip strength or arm drift?
ETOH/substance involvement?
12-lead interpretation?
Location of probes?
Number of shots?
Number of shocks?
ETOH/substance involvement?
Probes removed by?
If there is an injury, follow appropriate benchmarks.
Abdominal p[ain?
Nausea?
Vertigo?
Postural?
Pregnant?
Last menstrual period?
Describe clot, tissue, etc.
Amount (estimate)?
Number of pads saturated through?
Hemiplegia?
Grip strength or arm drift?
Dysphasic? Aphasic? (speech)
Dysphagia? Aphagia? (swallowing)
Onset or signs/symptoms?
Facial droop?
Confusion, hallucinations, stupor, delirium?
Vertigo?
Focal weakness, abnormal movements?
Slurred speech?
Unsteady gait?
Patient able to sit up without assistance?
Headache?
Nausea, vomiting, diarrhea, constipation?
BGL?
Fever?
12-lead interpretation?