Adult Male – Psych

This narrative is part of a patient care report (PCR). The narrative is intended to be considered and construed along with the information in the other parts of the PCR. This PCR was initially prepared close in time to the events of the incident. However, nothing in the narrative, or any other part of the PCR, shall be construed as a representation that all possibly relevant information and facts were available, known to, or recorded by the author in the limited time available at initial creation. The author reserves the right to amend or supplement the PCR with relevant information or facts at any later time.

PATIENT HISTORY

Unit _______ was dispatched to transport pt from _____________to ________ .

Based on information received from dispatch, on-scene, and during transport, it was the author’s understanding that pt is a ___-year-old male with a history of ____________________.

Prior to arrival on scene pt ___________________________________________

At the time of transport, the reported medications for the patient were ________________.

The patient was reported to be full code status.

The pt was reported to have allergies __________________________________.

*************** ASSESSMENT ******************

On scene, pt was found to be AOx____, GCS ______. The reported baseline for patient was ___________________. The chief complaint expressed by pt at the time of crew contact was _________________. Consent was received from ___________ for assessment and transportation of pt by crew.

Physical examination of the patient revealed _____________________________________

There was no observation or reports on the scene of anything that departed from the reported normal baseline of pt regarding acute focal neurological deficits, AMS, chest pain, shortness of breath, or syncope/near syncope. There were no abnormal vital signs in the patient that would require an ALS assessment (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 pt, 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.

*************** TREATMENTS ON SCENE **************************

There were no immediate life threats to the patient observed or treated on scene.

After arrival at the patient and before departure, the pt received treatment from _______ consisting of __________.

************** TRANSPORT DECISION ******************

Based on the assessment, it was determined that transport of the patient to the destination by BLS ambulance was appropriate because ________________________

********************** TRANSPORT *******************************

The crew transferred the patient to the ambulance gurney by ________. Soft velcro restraints were applied to the patient’s wrists, the gurney rails were raised, the patient was covered with ______________, and the patient was secured with all straps. CMS of the patient’s restrained extremities was assessed at the time of application and regularly throughout transport. The crew moved the patient and any patient belongings identified into the ambulance without incident.

During transport, the author continuously monitored and periodically assessed the patient. The patient was __________________. The patient’s condition and vital signs were __________.

***************** PATIENT DELIVERY ***************************

At the destination, the patient was unloaded from the ambulance and moved to the patient receiving area without incident. The gurney was lowered, the safety straps and restraints were removed, the rails lowered, and the patient was assisted to the location identified by the staff for placement of the patient. The patient’s condition had not changed detrimentally or materially since the time of pick-up. The patient’s belongings were left with staff in the receiving area. A verbal report was offered or given to ______________. Care was transferred, and the call was completed without incident.