Patient Care Report
Scene: ____ ---> Destination: _____
ALS or BLS IFT or 911
Unit:
Arrived on scene to find patient, a __ year old male/female, complaining of _________. Patient was in the _____ position.
*** Back story ***
Patient was transferred to stretcher via ______. Patient was secured with safety belts and stretcher railings. Patient was loaded into ambulance without incident.
Medical History:
Meds:
Allergies:
Vitals: GCS; BP; P; O2; AVPU; AOx4; pulse, motor, and sensory in all 4 extremities; skin warm, pink, and dry; pain; lung sounds; etco2; eyes equal and reactive.
Head: Stable, intact, negative DCAPBTLS
Neck: Intact, stable, negative tracheal deviation, negative JVD and negative DCAPBTLS.
Back: Intact, stable and negative DCAPBTLS.
Chest: Intact, stable, negative DCAPBTLS.
Abdomen: Intact, soft non-tender, and negative DCAPBTLS.
Pelvis: Stable and intact
Upper Extremities: Stable; intact; pulse, motor, and sensory present; and negative DCAPTBLS.
Lower Extremities: Stable; intact; pulse, motor, and sensory present; and negative DCAPBTLS.
Treatment for Pt consisted taking vitals and reassessing PT condition.
Patient was transported to ____ without incident. Patient was transferred to hospital bed without incident. Patient was left under the observation and care of hospital nursing staff.