Adult Male – O2

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 at __ to transport the patient from __ to __. The medical information communicated by dispatch concerning the patient was _. The crew arrived at the scene where the patient was at __. Contact was made with staff __ at __. The crew made contact with the patient at __. The patient was transferred to the ambulance gurney at __. Any delay between the arrival of the crew at the scene and transfer to the ambulance gurney was due to the time taken __.

Based on information received from dispatch, on-scene, and during transport, the author understood that the patient is a _-year-old male with a medical history of __.

The history of the present illness reported to the crew by _, and a review of any medical records made available for inspection, was that the patient _.

For medications, the information received from medical records, a review of medications present, or individuals at the scene and the destination was that the patient __.

For allergies, The patient was reported by __ to have __.

For resuscitation efforts outside of a licensed healthcare facility, documents presented to the crew did __ include either a fully executed POLST, fully executed advanced healthcare directive, fully executed EMSA/CMA Prehospital Do Not Resuscitate Form, or a DNR medallion from an approved medallion provider.

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

Consent was received from _ for the assessment and transportation of the patient by the crew. The baseline for the patient was reported by _ to be _.

The eyes of the patient

The patient could open their eyes and keep them open on their own.
The patient’s eyes would only stay open when verbally told to do so, otherwise they were closed
The patient’s eyes would only open in response to pain.
The patient’s eyes would not open.

Verbally, the patient __________

At the scene, the crew found the patient to be AOx_, GCS _. During initial crew contact, the patient denied ____ and reported pain of ___ present ____.

Initial physical examination of the scene and the patient by the crew revealed __

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. There were no abnormal vital signs for 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 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.

*************** 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 patient received treatment from __ consisting of ___.

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

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

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

The patient was transferred to the ambulance gurney by ___ without incident. The gurney rails were raised, and the patient was covered with __and secured with all straps. The patient was connected to ambulance gurney O2 at __ LPM by ___. The crew moved and loaded the patient and any patient belongings that the crew had identified into the ambulance without incident. The patient was switched to ambulance O2 at _ LPM by ___ once in the ambulance.

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 connected to gurney O2 at __ LPM by ___, and the crew unloaded the patient from the ambulance without incident. The crew moved the patient to __ without incident. The patient was switched to an O2 source at the destination on __ LPM by ___. The patient was assessed again by crew, and the patient’s condition had not changed detrimentally or materially since the time of pick-up. Any patient belongings transported were left with __ in __. A verbal report was offered or given to __.

Care was transferred, and the call was completed without incident.