Chief Complaint
History of Presenting Illness
Pertinent positives, relative negatives, associated symptoms, information relayed by people at the scene
This is also where you will add how you found the patient and how you moved the patient. Be specific
and through on this.
The patient denied LOC, headache, change in vision, dizziness, shortness of breath, nausea, vomiting,
diarrhea, chest pain, ABD pain, neck pain, back pain, ETOH, drugs, recent trauma, and recent illness.
Physical Exam/ Data Gathering
All the stuff you discovered via your assessment and
diagnostic tools
This includes anything you can see, touch or smell. This description is a snapshot of your patient’s initial
Presentation. Changes to the patient’s presentation due to treatment
or progressing pathology can be documented later. There is only one physical exam
MENTAL STATUS: Oriented to Person, Place, Time, Event
SPEECH: Clear with an even cadence.
SKIN: Pink, warm, dry
Head: Appears normal upon exam.
Ears: Appears normal upon exam.
Eyes: Equal and reactive to light
Nose: Appears normal upon exam
Throat: Appears normal upon exam
CHEST: Equal rise and fall.
RESPIRATIONS: Normal and uncompromised.
LUNG SOUNDS: Clear and equal bilaterally/rales/rhonchi/crackles/wheezing/diminished]
ABDOMEN: Soft non-tender in all 4 quadrants.
CTLS: No pain, deformity, or crepitus noted on Cervical, Thoracic, Lumbar or Sacral Spine.
BACK: Appears normal upon exam.
PELVIS: Able to walk without assistance.
EXTREMITIES: Good circulation/sensation/movement of extremities X 4.
Discussion/ Impression
This paragraph allows you to document your thought processes and decision
making
We make judgment calls all the time when treating patients or making
disposition decisions
This is where you justify your course
Plan
This section allows you to lay out how you would treat
the patient in best- and worst- case scenarios
Treatment
Document the interventions the patient did
receive, as well as any changes in presentation
or response to treatment
If details are being provided elsewhere in the report,
this can be a synopsis of the treatment