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History Taking For the EMT
MORE INFORMATION
ON HISTORY TAKING
PCR’s PERSONAL CARE REPORTS
~LWF0000
PCR -GENERAL FORMAT
This fonnat was included to provide a general fonnat for PCR writing. It is not mandatory, however it is important to include the infonnation, which is pertinent to your patient, and patient condition. The fonnat in which you present that is your choice, providing it is presented in an organized fonnat. It is also important to remember to include pertinent negatives.
0/:4 -On arrival
. .Includes what you found on arrival at scene .Description of scene if pertinent .Location and position of patient (eg. patient found supine on kitchen floor) General impression of pt -degree of distress (no distress, mild, moderate, severe)
C/C -Chief complaint .Describes in the patients' words why the ambulance was called .If multiple complaints -the most concerning for the patient (eg. my chest hurts)
C/o -Complaining of .Other complaints the patient expresses (eg. weakness, nausea)
HPI -History of present illness/injury .Describes the events leading up to the illness/injury .Also includes associated complaints and pertinent negatives (eg. gradual onset of substernal chest pain approximately one hour ago, no precipitating events, pain worsened over first few minutes, radiating to left arm, accompanied by dyspnea and diaphoresis, no nausea, denies any history of similar pain.) .If trauma, include description of mechanism of injury
PMHX -Past medical history .Include all pertinent past medical history .Especially -cardiac, respiratory, diabetes, seizure disorder, liver and kidney disorders, communicable diseases
OlE -On examination .This section attempts to present a systematic organized approach to your findings
TX -Treatment provided .Describes treatment provided .Oxygen -device and flow rate .IV -size, solution, site, rate (also includes number of unsuccessful starts .Splinting -describe here or in assessment section, circulation of limb after splinted) .Meds -dosage, route, time .Intubation -size of ETT, secured, placement check, lung sounds (These are some examples of treatment which require documentation)
E/R -Evaluation of treatment provided by reassessment ojpatient on route to hospital .Includes subjective and objective data .Improvement or deterioration of patient condition
file:///C|/DOCUME~1/Owner/LOCALS~1/Temp/~LWF0000.htm [6/4/2003 5:52:08 PM]
~LWF0001
Medical / Trauma OlE
CNS -as.~es.~ment of central nervou~ .sy.~tem .Level of consciousness .GCS .Pill
CVS -assessment of cardiovascular system .Peripheral pulse (usually radial) -general rate, strength, rhythm .Jugular venous distension (assessed with pt at 45 degree angle) .Description/interpretation of rhythm on monitor, indicating lead selected.Skin temperature, colour, condition
HEENT -head! eyes! ears/nose/throat .Airway patency .Regular/irregular respirations, noisy, snoring etc .Pupils -size, equal, reactive to light, how fast .Headache/dizziness, ringing in ears .Drainage -ears/nose/mouth .Facial trauma .Tracheal shift/tug .Tendemess/defonnity to neck to neck .Assessment of cranial nerves if pertinent
CHEST .Respiratory effort -indrawing, use of accessory muscles, supra/sub sterna indrawing, intercostal indrawing) Expansion of chest with respirations, equaVunequal bilateral Depth of respirations Air entry (AlE) description -clear, crackles (fine/coarse), wheezes, congestion, decreased air entry, (note there are 5 lobes). Indicate which part of chest adventitious sounds heard (eg. RLL) Pain or discomfort Stability Injuries Scars Medication patches
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Approved bv: :Dr. ~;J;to/
Uate: September IJ, 2UUU
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file:///C|/DOCUME~1/Owner/LOCALS~1/Temp/~LWF0001.htm [6/4/2003 5:54:52 PM]
