Assessment

*************** PATIENT ASSESSMENT ******************

The patient was found ____ and was wearing ___.  There were no immediate life threats to the patient observed. The general impression of the patient on first contact was __. 

The crew found the patient at the scene AOx_, GCS _. 

The patient reported __ pain of __ / 10 at __.

The patient denied any headache, vision problems, hearing difficulty, breathing difficulty, nausea, vomiting, diarrhea, numbness, tingling, or temperature discomfort.

The airway was ___, and breathing was ___.

The patient’s lungs were auscultated and ___.

The skin signs of the patient were ___.

The CMS of the patient’s extremities was checked and showed ___.

The forehead temperature of the patient was ___.

The patient’s pupils were __.

There were __ reported or observed wounds or skin conditions of ___

There were __ medical devices consisting of __ observed or reported by __.

The need for an ALS assessment or upgrade was considered.

There was no observation or reports on the scene of anything that departed from the reported normal baseline of the patient regarding acute focal neurological deficits, AMS, chest pain, shortness of breath, or syncope/near syncope. If the patient was a female of child-bearing age, there was no pregnancy greater than or equal to 20 weeks with vaginal bleeding. There were no abnormal vital signs for the patient that would require an ALS assessment (e.g., ADULT: hr ≥ 120, SBP < 90, RR ≥ 24, and SpO2 < 94% (88% COPD) on the regular flow rate of oxygen for the patient that was sustained or deteriorating over two measurements 5 minutes apart)

From the information reported on scene and crew assessment of the patient, there was no impression of any present agitated delirium, anaphylaxis, cardiac arrest, dystonic reaction, hypotension, respiratory failure, shock, stroke/CVA/TIA, airway obstruction with severe respiratory distress or respiratory arrest, a persistent ALOC of unclear etiology, rapid Afib with poor perfusion, symptomatic bradycardia, wide complex tachycardia, ventricular assist device malfunction, signing out AMA with overdose/poisoning/ingestion, or status epilepticus. There was also no impression of the patient having any untreated traumatic injury.

Accordingly, it was determined that there was __ need for an ALS assessment or upgrade.