Documentation Guidance: Difference between revisions

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== Section 1 - ADMINISTRATIVE POLICIES ==
== Section 1 - ADMINISTRATIVE POLICIES ==
=== 1.23 Documentation Guidance ===
=== 1.23 Documentation Guidance ===
 
The following are lists of documentation guidance for different types of patients.  Each list should be considered the baseline documentation for each complaint.
==== ALL PATIENTS ====
==== ALL PATIENTS ====
#How patient found (position/location)
#How patient found (position/location)
Line 7: Line 7:
#LOC (explain abnormals)
#LOC (explain abnormals)
#OPQRST
#OPQRST
#At least one set of vitals (before and after treatment as well) (Pulse, B/P, Respiratory rate)  (temp, O2 sat, CO2, EKG, etc. as indicated)
#At least one set of vitals (before and after treatment as well) (Pulse, B/P, Respiratory rate)  (temp, O2 sat, CO2, EKG, BSL, etc. as indicated)
#Medical Hx (document if medical alert is present)
#Medical Hx (document if medical alert is present)
#Explore previous treatment compliance.
#Explore previous treatment compliance.
Line 864: Line 864:
#Last Tetanus shot?
#Last Tetanus shot?
 
 
TRAUMA ALERT
==== VAGINAL HEMORRHAGE ====
1. Complete Trauma Alert Form
#Abdominal pain? (describe) PQRST
2. Follow appropriate benchmarks
#Nausea/vomiting
3. Full Trauma Assessment
#LMP
4. Interventions
#Vertigo? Postural?  
VAGINAL HEMORRHAGE
#Describe (clot, tissue, etc.)?
1. Abdominal pain? (describe) PQRST
#Amount (estimate)? (number of pads, tampons over what time frame)
2. Nausea/vomiting
#LOC
3. LMP
#GCS
4. Vertigo? Postural?  
#Cap refill
5. Describe (clot, tissue, etc.)?
#Conjunctiva
6. Amount (estimate)? (number of pads, tampons over what time frame)
#Skin Color/Temp
7. LOC
#Orthostatic Vitals
8. GCS
#Interventions by FD/others
9. Cap refill
#How was patient moved to stretcher?
10. Conjunctiva
11. Skin Color/Temp
12. Orthostatic Vitals
13. Interventions by FD/others
14. How was patient moved to stretcher?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


==== WEAKNESS/CVA ====
#SEE STROKE / CVA / TIA BENCHMARKS
#Dysphasic? Aphasic?
#Onset of signs/symptoms?
#Confusion, Hallucinations, Stupor, Delirium
#Vertigo, Focal weakness, Abnormal movements, slurred speech,
#Patient able to sit up without assistance?
#Respiratory Effort
#Lung Sounds
#New Meds?
#Headache?
#Vision changes or visual field issues?
#Eye deviation?
#Nystagmus?
#Pupils
#Cap refill
#Conjunctiva
#Fever?
#Rash?
#MEND
#EKG (12 Lead)
#MM (tongue)
#Skin color/Temp
#Recent illness, travel, visitors, etc.
#Orthostatic Vitals
#Nausea/vomit/diarrhea/constipation?
#BGL
#Sepsis Alert? Stroke? Cardiac?
#Interventions by agency
#How was patient moved to stretcher?


=== Extra Credit ===
#If hypocalcemia is suspected (patient with recent surgery on parathyroid) *  (+) or (-) “Trousseaus”  (contracture of forearm when B/P cuff is inflated on upper arm)
#“Homonymous Hemianopia”  Loss of vision on one side in both visual fields (upper and lower)  *Caused by a cerebral occlusion
#“Asterixis”  non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy)  (in alcoholic patients)
#Acute narrow angle closure glaucoma:  dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.*Caused by certain medications:  * (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin), dim light, and rapid correction of hyperglycemia.  Trauma.


WEAKNESS/CVA
[[Category:Administrative Policies|0123]]
1. SEE STROKE / CVA / TIA BENCHMARKS
2. Dysphasic? Aphasic?
3. Onset of signs/symptoms?
4. Confusion, Hallucinations, Stupor, Delirium
5. Vertigo, Focal weakness, Abnormal movements, slurred speech,
6. Patient able to sit up without assistance?
7. Respiratory Effort
8. Lung Sounds
9. New Meds?
10. Headache?
11. Vision changes or visual field issues?
12. Eye deviation?
13. Nystagmus?
14. Pupils
15. Cap refill
16. Conjunctiva
17. Fever?
18. Rash?
19. MEND
20. EKG (12 Lead)
21. MM (tongue)
22. Skin color/Temp
23. Recent illness, travel, visitors, etc.
24. Orthostatic Vitals
25. Nausea/vomit/diarrhea/constipation?
26. BGL
27. Sepsis Alert? Stroke? Cardiac?
28. Interventions by agency
29. How was patient moved to stretcher?
***Extra Credit: 
1. If hypocalcemia is suspected (patient with recent surgery on parathyroid) *  (+) or (-) “Trousseaus”  (contracture of forearm when B/P cuff is inflated on upper arm)
2. “Homonymous Hemianopia”  Loss of vision on one side in both visual fields (upper and lower)  *Caused by a cerebral occlusion
3. “Asterixis”  non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy)  (in alcoholic patients)
Acute narrow angle closure glaucoma:  dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.*Caused by certain medications: * (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin),[10, 11, 12, 13, 14] dim light, and rapid correction of hyperglycemia.  Trauma.

Latest revision as of 13:46, 24 June 2024

Section 1 - ADMINISTRATIVE POLICIES

1.23 Documentation Guidance

The following are lists of documentation guidance for different types of patients. Each list should be considered the baseline documentation for each complaint.

ALL PATIENTS

  1. How patient found (position/location)
  2. GCS(explain abnormals)
  3. LOC (explain abnormals)
  4. OPQRST
  5. At least one set of vitals (before and after treatment as well) (Pulse, B/P, Respiratory rate) (temp, O2 sat, CO2, EKG, BSL, etc. as indicated)
  6. Medical Hx (document if medical alert is present)
  7. Explore previous treatment compliance.
  8. Surgical History (visible scars) (document) (Still have all organs?)
  9. Previous Hospitalizations
  10. Name of physicians involved in care (cardiologist, OB/GYN, etc.)
  11. Current medications (name, dose, frequency, last taken) **Proper spelling. (If medications were transported to the hospital due to high number, document how they were handled) (secured in Ziploc, labeled, pinned to pt., nurse notified)
  12. Advanced Directives (DNR, Living Will, DPOA, Healthcare Surrogate, etc.) if applicable.
  13. OTC, Recreational, Herbal medications
  14. Recent Travel outside US (visitors from outside the US) *Medical Patients
  15. Allergies (be specific as to what reaction they have)
  16. All female patients of childbearing age (OB hx: (GPA) LMP)
  17. Alcohol/Tobacco use (if applicable) (cardiac, stroke, etc.)
  18. Any prosthesis (document)
  19. Glasses, dentures, hearing aids (document if in place and that nursing staff notified)
  20. Presence of ports, a/v fistula, arterial lines, PICC, implantable devices, indwelling cath, suprapubic cath, etc.
  21. Hx: Mastectomy (which side) (presence of lymph edema) (nursing staff notified to avoid IV, B/P, etc. on that side)
  22. If on blood thinners (last INR results/Date)
  23. Trauma patients (deep breath and cough without splinting)
  24. Any reductions of dislocations (assessed ROM)
  25. Condition after any treatment
  26. Name of nurse receiving report
  27. Terminology for refusals (EMS assessment was within normal limits, however, only an assessment at the hospital can diagnose any condition; the patient may still have an underlying condition and by refusing to seek further medical attention at the hospital the patient risks possible disability or death. Informed Patient of signs and symptoms to be aware of which may indicate condition is worsening and to immediately call 911/ seek immediate medical attention at the hospital. Patient acknowledges symptoms to be aware of and accepts risks of refusing transport to the hospital. Contacted [ ], who approved refusal request.)
  28. Terminology for dry-runs (This individual stated they have no injuries. My observations concurred. The individual refused examination and did not request transport. The individual was advised to seek further medical attention if deemed necessary.)
  29. Terminology for presence of alcohol on breath (Patient’s breath had an odor consistent with the impurities of ETOH)
  30. Describe emesis, sputum, discharge, etc.

ABDOMINAL PAIN/PROBLEM

  1. Description (pain level) (tearing, radiating, cramping, burning, stabbing, etc. )Location of pain? (flank, groin, quadrant, epigastric, etc.) (pain on percussion at costovertebral angle)
  2. Radiation to back or shoulder?
  3. Distension?
  4. Tenderness on palpation?
  5. Empty stomach, recent meal? (decrease in appetite over several days?)
  6. Position of comfort (fetal, knees flexed, etc.)
  7. Nausea/Vomiting/Diarrhea/constipation (describe emesis, stool) (presence of blood/mucus)
  8. Urinary complaints?(frequency, burning, minimal output, blood, odor, cloudy, etc.)
  9. Femoral pulses
  10. LMP, women of child bearing age
  11. Vaginal bleeding/discharge
  12. Skin color/temp (jaundice, pale, flushed)
  13. Conjunctiva
  14. Cap Refill
  15. Mucous Membranes (moist tongue)
  16. Sclera (jaundice?)
  17. Extremities (color/temp) (shunting?)
  18. Orthostatic vitals
  19. 12 lead
  20. Breath sounds
  21. Sepsis Alert? (if applicable)
  22. Interventions by agency
  23. How was patient moved to stretcher?

AIRWAY OBSTRUCTION

  1. Can patient speak/forcibly cough?
  2. Is patient moving air?
  3. Inspiratory stridor?
  4. Circumoral cyanosis?
  5. Drooling?
  6. What caused obstruction?
  7. Duration of obstruction
  8. Lung sounds
  9. Interventions by agency
  10. How was patient moved to stretcher?

ALCOHOL INTOXICATION

  1. “Patient’s breath had an odor consistent with the impurities of ETOH.”
  2. Patient admits to drinking? (type, amount, time frame)
  3. Other intoxicants (medications, recreational drugs)
  4. Speech (normal, slurred)
  5. Gait (Normal, ataxic)
  6. Nystagmus
  7. Pupils
  8. MEND
  9. Cherry Red Tongue (B12 deficiency) (if present)
  10. Skin Color (jaundice?)
  11. Sclera (jaundice)?
  12. Distended abdomen? (ascites, wave, vascular)
  13. Sepsis screening (if appropriate)
  14. Obvious head/facial injury?
  15. Blood Glucose Level
  16. Vomiting (blood present?
  17. Signs of dehydration (tongue moisture, Orthostatic Vitals)
  18. Extremities
  19. EKG
  20. Asterixis (if present)
  21. Altered Mental Status?
  22. Interventions by agency
  23. How was patient moved to stretcher?
  24. Obvious signs of prior injuries (from falls, etc.)

ALLERGIC REACTION

  1. Cause of reaction?
  2. Timing?
  3. Dyspnea?
  4. Lung Sounds
  5. Facial (eyes, lips)/throat edema? (sensation of swollen tongue?)
  6. Chest pain?
  7. Rash/Itching?
  8. Urticaria (hives)
  9. Cap Refill
  10. Nausea/Vomiting (caused by edema in GI tract)
  11. Interventions by agency
  12. How was patient moved to stretcher?

ALTERED LEVEL CONSCIOUSNESS

  1. OPQRST, Sample as appropriate
  2. Specify deficits in LOC/GCS
  3. What is normal mentation for patient?
  4. ETOH/Substance involvement?
  5. Obvious head/facial injury
  6. Other injuries?
  7. MEND
  8. Pupils
  9. Conjunctiva
  10. Vagal Causes (rule out)
  11. 12 lead
  12. New medications, or those that cause ALOC
  13. Nystagmus?
  14. BGL?
  15. Usual level of consciousness/GCS?
  16. Interventions by agency
  17. How was patient moved to stretcher?

ANIMAL BITE

  1. Type of animal
  2. Location of bite(s)
  3. Edema at site?
  4. Rabies/immunization status of animal
  5. Status of patient immunization (Tetanus)
  6. Interventions by agency
  7. How was patient moved to stretcher?

ASSAULT/FIGHT

  1. OPQRST, Sample as appropriate
  2. Trauma Assessment (presence of injuries) (pertinent negatives for specific injury or lack thereof)
  3. GCS
  4. Method of assault? (weapon?)
  5. Loss of consciousness? How long?
  6. PMS before/after assessment/intervention?
  7. Neck/Back pain?
  8. Paresthesia?
  9. ETOH/Substance involvement?
  10. Interventions by agency
  11. How was patient moved to stretcher?

ATRAUMATIC (GI) BLEED

  1. Nausea/vomit/diarrhea/constipation?
  2. Conjunctiva
  3. Cap refill
  4. Orthostatic Vitals
  5. Active bleeding?
  6. Bloody emesis/stool? How long?
  7. Color of emesis/stool
  8. Abdominal pain? Location and quality? (OPQRST)
  9. ETOH/Substance involvement?
  10. Interventions by agency
  11. How was patient moved to stretcher?

BAKER ACT/Incapacitation

  1. Law enforcement agency initiating
  2. Law enforcement officer/Physician name
  3. Reason?
  4. BGL, for altered LOC.
  5. ETOH/Substance involvement?
  6. MEND
  7. Pupils
  8. Agitation? (if excited delirium – body temp)
  9. Method of restraint, as appropriate
  10. Position of restraint, as appropriate (never prone)
  11. Pulses and continuous assessment after restraint
  12. Interventions by agency


BEHAVIORAL/PSYCHIATRIC DISORDER

  1. What is the patient’s mood (agitated, withdrawn, catatonic, etc.)?
  2. Is the patient cooperative?
  3. Suicidal/Homicidal?
  4. Rate of speech (slow, fast, etc.)
  5. Are verbal responses appropriate?
  6. Method of restraint, if appropriate
  7. Position of restraint, if appropriate (never prone)
  8. Continuous evaluation if restrained.
  9. ETOH/Substance involvement?
  10. See Baker Act, if appropriate
  11. BGL?
  12. Vomiting/ Diarrhea?
  13. Interventions by agency
  14. How was patient moved to stretcher?

BURN (ELECTRICAL)/LIGHTNING

  1. Voltage, if known
  2. Duration of contact?
  3. Fall?
  4. Entrance wound(s)?
  5. Exit wound(s)?
  6. 12 Lead EKG
  7. Pain from burns? Rate
  8. Neck/Back pain?
  9. Loss of consciousness?
  10. Paresthesia?
  11. Presence of other injuries? Trauma Assessment
  12. Interventions by agency
  13. How was patient moved to stretcher?

BURN (THERMAL)

  1. Burn source?
  2. Exposure time?
  3. Describe environment (enclosed, etc.)
  4. BSA involved
  5. Severity (degree) of burn(s)
  6. Facial hair singed?
  7. Nasal hair singed?
  8. Dyspnea?
  9. Oral edema?
  10. Lung Sounds
  11. Presence of injuries?
  12. ETOH/Substance involvement?
  13. Interventions by agency
  14. How was patient moved to stretcher?

CARDIAC ARREST

  1. Circumstances at onset (any complaint prior to arrest?) (Respiratory, trauma, etc.)
  2. Witnessed arrest (by FD or by other)?
  3. Bystander CPR?
  4. Description of patient upon agency arrival
  5. Estimated down time before intervention. Time of onset?
  6. H’s & T’s?
  7. Trauma Assessment if applicable
  8. Interventions by agency. Timeline accurate?
  9. How was patient moved to stretcher?
  10. Physician authorizing cessation of efforts? Reason?
  11. Presence of advanced directives (any disagreement from family)
  12. BGL
  13. If dialysis pt. (last dialysis treatment) (report card)
  14. ROSC Treatment? GCS?
  15. Cardiologist?
  16. Code summary

CARDIAC RHYTHM DISTURBANCE

  1. Chest pain?
  2. Dyspnea?
  3. Nausea/Vomiting?
  4. Diaphoresis?
  5. Cap refill?
  6. Other signs/symptoms (tachycardia, bradycardia, ectopy, etc.)
  7. ECG rhythm? V4 R (recent EKG available for comparison?)
  8. Vagal Stimulus?
  9. Caffeine Intake?
  10. Meds or Recreational drugs?
  11. Cardiologist? Previous Interventions
  12. Lung sounds
  13. Pretibial Edema?
  14. Other Edema?
  15. Dialysis Pt. (last treatment?) (Report Card)
  16. Cardiac Alert? Stemi Alert?
  17. Interventions by agency
  18. How was patient moved to stretcher?

CHEST PAIN/DISCOMFORT

  1. OPQRST, Sample
  2. Location of pain
  3. Level of Pain (rate)
  4. Radiation? (Jaw, shoulder, neck, arm, back)
  5. Skin color/Temp
  6. Cap refill
  7. MM (tongue- moist/dry?)
  8. Dyspnea?
  9. Nausea/Vomiting?
  10. Pre-tibial edema? Other edema present?
  11. Diaphoresis?
  12. Lung sounds
  13. Hx Cardiac Interventions?
  14. Cardiologist?
  15. Recent calf pain?
  16. Recent other surgery or immobilization (fx)?
  17. Fever?
  18. Cough? Hemoptysis?
  19. Recent viral illness? Night Sweats?
  20. Recent Trauma or fall?
  21. Erectile dysfunction RX within 24 hours?
  22. Aspirin within 12 hours?
  23. 12 lead ECG? Mimics? (Recent 12 lead available for comparison)?
  24. Thrombolytic exclusionary criteria complete?
  25. Cardiac or Stemi alert?
  26. Interventions by agency?
  27. How was patient moved to stretcher?

CHF/PULMONARY EDEMA

  1. Position of Pt. (tripoding?)
  2. Chest pain?
  3. Dyspnea? (at rest, exertion? (nocturnal/orthopnea?)
  4. Nausea/Vomiting?
  5. Pre-tibial edema? Other edema? (pitting?)
  6. JVD (At what position?)
  7. Diaphoresis?
  8. Cough? (productive?) (frothy?)
  9. Hemoptysis?
  10. Cap Refill
  11. Skin color/temp (fever?)
  12. Lung sounds
  13. 12 lead
  14. Mucous membranes (tongue?)
  15. Urine OP? (Ask pt.)
  16. Abd distention? Acites, wave?
  17. Interventions by agency?
  18. CPAP Applied/ Response?
  19. How was patient moved to stretcher?

DEATH

  1. Time of death?
  2. Position/Location of body at agency arrival/time
  3. Observations of the scene
  4. Any repositioning of the body?
  5. 3 lead? (if not, why? i.e. crime scene with obvious death)
  6. Presence of injuries?
  7. Dependent lividity? (where?)
  8. Rigor mortis? (jaw, extremity?)
  9. Person pronouncing death?
  10. Interventions by agency
  11. Law enforcement notified /on-scene

DIABETIC SYMPTOMS

  1. Diagnosis type (I or II)
  2. LOC & GCS
  3. Last meal?
  4. Last time medication taken, if applicable? Compliant patient?
  5. Insulin Pump? (on or off?)
  6. Oral mucosa moist or dry? (tongue)
  7. Oral trauma (post seizure)
  8. Breath Odor?
  9. Alcohol intake?
  10. Skin Temp/turgor
  11. Cap refill
  12. Nausea/Vomiting?
  13. Diarrhea?
  14. MEND
  15. Excessive exertion?
  16. Pre & post intervention BGL?
  17. 12 lead
  18. Interventions by agency
  19. Stroke or Sepsis Alert?
  20. How was patient moved to stretcher?

DIGESTIVE SYMPTOMS (nausea/vomiting/diarrhea)

  1. Nausea/Vomiting? (describe emesis)
  2. Diarrhea/Constipation?
  3. Last solid food retained
  4. Last fluid retained
  5. MM Moist (tongue)/ Skin turgor
  6. Conjunctiva
  7. Presence of injuries?
  8. Dark (coffee ground or Bloody emesis/ dark stool?
  9. Fever?
  10. Vertigo?
  11. Anyone else in household sick? Recent Travel?
  12. Sclera (jaundice)
  13. H/A?
  14. Rash?
  15. Orthostatic Vitals
  16. 12 lead
  17. ABD exam
  18. Vagal component?
  19. Interventions by agency?
  20. How was patient moved to stretcher?

DROWNING/NEAR DROWNING

  1. OPQRST, Sample
  2. Salt water, fresh water, brackish?
  3. Time submerged? / Describe MOI
  4. Water temperature, if known?
  5. Skin Temp
  6. Cap Refill
  7. Lung Sounds
  8. Dyspnea?
  9. Vomiting? (water or food)
  10. Presence of injuries?
  11. Neck/Back pain?
  12. Paresthesia?
  13. Loss of consciousness?
  14. PMS before/after assessment/intervention? (if injury suspected)
  15. 12 lead
  16. ETOH/Substance involvement?
  17. Interventions by FD/others?
  18. How was patient moved to stretcher?

FALL

  1. Presence of injuries?
  2. Loss of consciousness? How long?
  3. GCS/LOC
  4. Trauma Assessment
  5. EKG if indicated
  6. PMS before/after assessment/intervention
  7. Describe MOI (Tripped, slipped, etc.) (or dizzy then fell)
  8. Height of fall & surface struck
  9. Hx: Blood thinners
  10. Lung sounds
  11. Conjunctiva
  12. MEND
  13. Pain level (rate)
  14. Neck/Back pain?
  15. Paresthesia?
  16. ETOH/Substance involvement?
  17. Interventions by agency
  18. How was patient moved to stretcher?

FEVER

  1. Illness associated? (household illness?)
  2. Recent injury/obvious wounds
  3. Nausea/vomiting/diarrhea/constipation?
  4. Urinary Symptoms (indwelling catheter?)
  5. How long?
  6. Headache?
  7. Rash? Petechiae?
  8. Nuchal rigidity?
  9. Skin turgor? Skin color?
  10. MM – tongue
  11. Cough? Productive?
  12. Night Sweats?
  13. Lung sounds
  14. Sclera
  15. Conjunctiva
  16. Cap refill
  17. Pertinent negatives (Pre-tibial edema)
  18. Sepsis Worksheet?
  19. Recent travel outside US? Family/visitors?
  20. Orthostatic Vitals if applicable
  21. Temperature
  22. Intervention prior to our arrival (Tylenol, Advil, etc.)
  23. FD Intervention

FIREARM

  1. Presence of injuries/Trauma Assessment
  2. Caliber of weapon/Range
  3. GCS
  4. Pain level (rate)
  5. Dyspnea? Lung Sounds
  6. Parathesia? PMS before/after assessment/intervention
  7. Trachea midline, as appropriate?
  8. JVD (+ or -)
  9. ETOH/Substance involvement
  10. Interventions by agency
  11. How was patient moved to stretcher
  12. Blood loss (estimate)

FLU-LIKE SYMPTOMS

  1. Describe complaint (pain associated?) (joint, abdomen, chest, etc.)
  2. Nausea/Vomiting/Diarrhea (describe frequency/content)
  3. Urinary issues
  4. Fever?
  5. Appetite Changes
  6. Mucous membranes (tongue)
  7. Skin turgor?
  8. H/A? Vision Issues?
  9. MEND
  10. Cough? Productive?
  11. Chest pain? (EKG)
  12. Lung sounds
  13. Sclera
  14. Recent travel/family illness or travel outside US?
  15. Cap refill
  16. Conjunctiva?
  17. BGL
  18. Pre-tibial edema?
  19. Flu shot/pneumonia vaccine UTD?
  20. Nuchal rigidity?
  21. Rash?
  22. Sepsis Checklist?
  23. Meds prior to FD Arrival (Advil, Tylenol, Tamiflu, antibiotics, etc.)
  24. Orthostatic Vitals if appropriate
  25. 12 lead
  26. Interventions by agency
  27. How was patient moved to stretcher?

HEADACHE

  1. Onset? (sudden or gradual)
  2. Worse when bending over?
  3. MEND
  4. Pupils
  5. Hyphema?
  6. LOC/GCS
  7. Light sensitivity/vision changes?
  8. Neck supple or rigid?
  9. Fever?
  10. Rash?
  11. Nausea/vomiting?
  12. Vertigo?
  13. Nosebleed (if present)
  14. Recent Injury?
  15. Recent Illness?
  16. Dental issues (if present)
  17. Ear pain (if present)
  18. BGL
  19. 12 lead
  20. Is pt. on blood thinners? (INR?)

HEMORRHAGE/BLEEDING

  1. Circumstances surrounding hemorrhage?
  2. Presence of injuries?
  3. Trauma Assessment, as appropriate?
  4. Loss of consciousness?
  5. GCS
  6. Blood thinners?
  7. Blood Loss (estimate)
  8. Active Bleeding?
  9. MM
  10. Conjunctiva
  11. Skin Color/Temp
  12. Cap refill
  13. Orthostatic Vitals
  14. 12 lead
  15. ETOH/Substance involvement?
  16. Interventions by agency
  17. How was patient moved to stretcher?

HYPERTENSION

  1. Chest pain?
  2. 12 lead
  3. Dyspnea?
  4. Nausea/Vomiting?

Headache?

  1. LOC
  2. GCS
  3. MEND
  4. Pupils
  5. Hyphema?
  6. Nosebleed?
  7. Interventions by agency
  8. How was patient moved to stretcher?
  9. Transport position (semi-fowlers) (head elevated?)

HYPERTHERMIA

  1. Approximate ambient air temperature
  2. Estimated exposure time
  3. Type of environment (warehouse, outside, etc.)
  4. LOC
  5. GCS
  6. Fluid intake
  7. Skin Color/Temp/Turgor
  8. MM (tongue)
  9. Conjunctiva
  10. BGL
  11. EKG
  12. Nausea/Vomiting?
  13. ETOH/Substance involvement?
  14. Interventions by agency
  15. How was patient moved to stretcher?
  16. Antipsychotic or anesthetic induced?
  17. Recreational Drugs?
  18. Excited Delirium?

HYPOTHERMIA

  1. Approximate ambient air temperature or water temp
  2. Estimated exposure time
  3. Type of environment (warehouse, outside, etc.)
  4. LOC
  5. GCS
  6. BGL
  7. EKG (arrhythmias)
  8. Shivering?
  9. Cap Refill
  10. Skin color/Temp (mottling?)
  11. Sepsis Checklist? (if applicable)
  12. ETOH/Substance involvement?
  13. Interventions by agency
  14. How was patient moved to stretcher?

INHALATION INJURY

  1. Type of exposure (gas, products of fire, etc.)
  2. Duration of exposure
  3. Area of exposure (enclosed room, etc.)
  4. Super-Heated environment?
  5. Oral mucosa burns?
  6. Singed facial/nasal hair?
  7. Difficulty breathing
  8. Lung sounds
  9. EKG
  10. Difficulty swallowing?
  11. Hoarseness?
  12. Interventions by agency
  13. How was patient moved to stretcher?

INTUBATION

  1. Number of attempts
  2. Visualization of passage of ETT thru cords
  3. Size of tube and ETT depth at teeth
  4. Absence of epigastric sounds
  5. Presence of lung sounds
  6. Condensation
  7. CO2 detection
  8. How Secured?

MEDICATION REACTION

  1. Name of Medication
  2. Time taken
  3. Newly prescribed medication for pt?
  4. Dyspnea?
  5. Facial/throat edema? (sensation of swollen tongue?)
  6. Chest pain?
  7. Rash/Itching?
  8. Urticaria (hives)? Where?
  9. Pupils
  10. Dystonia?(describe)
  11. Nystagmus? (if present)
  12. Poison Control consulted?
  13. 12 lead
  14. Interventions by agency
  15. How was patient moved to stretcher?

MOTORCYCLE CRASH/MVC/PEDESTRIAN

  1. Presence of injuries? Location of patient in vehicle if applicable
  2. LOC
  3. GCS
  4. Loss of consciousness? How long?
  5. Trauma Assessment
  6. Pain Level
  7. PMS before/after assessment/intervention?
  8. Helmet? For MC
  9. Seat Belt?
  10. Describe MOI (Estimate speed, How far thrown, surface (grass/road),damage to other vehicle if applicable) (steering wheel, windshield, etc.)
  11. ETOH/Substance involvement?
  12. Interventions by agency
  13. How was patient moved to stretcher?

POISONING/DRUG INGESTION

  1. Name of substance
  2. Amount
  3. Method (skin, ingestion, etc.)
  4. Associated Injuries
  5. When?
  6. Accidental/Intentional?
  7. Vomiting since ingestion? Describe
  8. ETOH/Substance involvement?
  9. BGL
  10. Pupils
  11. Oral mucosa burns, if appropriate?
  12. Interventions by agency
  13. How was patient moved to stretcher?
  14. Poison Control consulted?

PREGNANCY/OB DELIVERY

  • Separate report required for the mother and each neonate
Non-Delivery
  1. Abdominal pain?
  2. Gravida? Para? Abortion?
  3. Length of gestation? LMP
  4. Due date
  5. Fetal Heart Tones
  6. Prenatal care? (OB GYN Name)
  7. Previous pregnancy related issues? Other medical issues, past delivery issues?
  8. DX of pre-eclampsia?
  9. HTN? Edema? Headache? Visual disturbances? Fever?
  10. Vaginal hemorrhage/discharge? If yes, describe?
  11. Mucous plug or bloody show presented?
  12. Membranes ruptured? Meconium present? (time)
  13. Contractions (frequency, duration, degree)
  14. MM (tongue)
  15. Conjunctiva
  16. Interventions by agency?
  17. How was patient moved to stretcher? Position of transport (LLR with head slightly elevated for pregnant patients to prevent hypotension)
Delivery
  1. Multiple gestation?
  2. Is baby head down according to pt?
  3. Crowning? Limb presentation?
  4. Cord care
  5. Uterine massage?
  6. Placental delivery? (transported with pt.)
Neonate
  1. Time of birth
  2. Thoroughly dried and warmed?
  3. Oral, endotracheal, nasal suctioning? Meconium Present?
  4. Muscle tone (activity)?
  5. General appearance? APGAR? (1 & 5 minutes)
  6. Interventions by agency?

REFUSAL OF SERVICE

  1. Vital Signs
  2. Patient alert and oriented x4
  3. GCS if applicable
  4. Presence/Absence of Drugs/Alcohol?
  5. Attempts at assessment/provision of care documented?
  6. Patient advised to seek care; risks/benefits explained?
  7. Legal Guardian or POA if applicable
  8. Waiver Completed?
  9. Refusal Statement included

RESPIRATORY DISTRESS or ARREST

  1. Patient’s position
  2. Anxiety level/Environment (if applicable)
  3. Sudden or gradual onset?
  4. Retractions?
  5. Speech fragmentation?
  6. JVD? At what position?
  7. Trachea midline?
  8. Angioedema? (ACE Inhibitors?)
  9. Pretibial edema (+ or -)
  10. Other edema (forehead, wrist, etc.)
  11. Chest pain?
  12. Nausea/vomiting?
  13. Cap refill
  14. Conjunctiva
  15. MM (tongue)
  16. Skin color/temp
  17. Lung Sounds
  18. 12 lead
  19. Cough (productive?- describe) (hemoptysis?)
  20. Recent immobility or surgery?
  21. Hx or current calf pain on standing or dorsiflexion ( (+) Homans sign)
  22. Dialysis Patient (last dialysis) (report card)
  23. Circumoral cyanosis?
  24. Pursed lips, accessory muscle use, nasal flaring?
  25. Fever?
  26. Night sweats?
  27. Recent Travel Outside US, recent illness of family members?
  28. Finger Clubbing?
  29. Previous Intubations/Ventilator?
  30. Treatment prior to FD arrival
  31. Interventions by agency
  32. How was patient moved to stretcher?
  • See Intubation Benchmarks

SEIZURE

  1. Hx of seizure? Same or different?
  2. Description of seizure activity
  3. Duration of seizure activity
  4. Postictal?
  5. Number of seizures
  6. Head/Facial/Oral trauma?
  7. Other injury?
  8. LOC
  9. GCS
  10. Pupils
  11. Fever?
  12. Recent Illness? (Travel outside US or visitors/family illness)
  13. H/A?
  14. Rash?
  15. Nuccal Rigidity? Or Supple?
  16. Incontinence (bowel or bladder)?
  17. ETOH/Substance involvement?
  18. BGL
  19. (+) Trousseau?
  20. Dialysis Patient? Last Dialysis? Report Card
  21. Cardiac Arrythmia? (EKG)
  22. Interventions by agency
  23. How was patient moved to stretcher?

SEXUAL ASSAULT/RAPE

  1. PD notified / on-scene?
  2. Method of assault
  3. Presence of injuries/Trauma Assessment
  4. LOC/GCS
  5. ETOH/Substance involvement?
  6. Has patient changed/showered etc. since assault?
  7. Interventions by agency
  8. Victims Advocate notified?
  9. How was patient moved to stretcher?

STINGS/VENOMOUS BITES

  1. Type of animal/insect
  2. Any known allergies?
  3. Stinger removed/scrapped?
  4. Location marked?
  5. Lung sounds
  6. Angioedema? Anaphylaxis, Sensation of tongue swelling?
  7. LOC
  8. GCS
  9. Interventions by agency
  10. How was patient moved to stretcher?

STABBING

  1. Description of injuries
  2. Type of weapon, if known?
  3. Length of weapon, if known
  4. GCS
  5. Trauma Assessment
  6. Loss of consciousness?
  7. Dyspnea?
  8. Breath Sounds
  9. EKG
  10. PMS before/after assessment/intervention
  11. Trachea midline, if applicable
  12. JVD at what position
  13. ETOH/Substance involvement?
  14. Intervention by agency
  15. How was patient moved to stretcher?

STROKE/CVA/TIA

  1. Onset / (last seen without symptoms)
  2. MEND
  3. Facial droop with smile
  4. Nystagmus?
  5. Visual field changes
  6. Gait?
  7. Pupils (pin point pons)
  8. Eyes (deviation)?
  9. Vision Changes?
  10. Neck supple or rigid?
  11. Fever?
  12. Rash?
  13. Headache?
  14. Nausea/Vomiting?
  15. Ability to phonate? (dysphasia/aphasia)
  16. Ability to swallow? (dysphagia) (drooling)
  17. Profound Hemiplegia?
  18. Patient able to sit upright without assistance? Transport position (semifowlers)
  19. BGL
  20. Thrombolytic exclusionary criteria?
  21. 12 lead
  22. Stroke Alert
  23. Interventions by agency
  24. How was patient moved to stretcher?

SYNCOPE/FAINTING

  1. Presence of injuries? (trauma assessment if related)
  2. LOC
  3. GCS
  4. H/A
  5. Chest pain?
  6. Dyspnea?
  7. Nausea/Vomiting/Diarrhea?
  8. Vertigo? Postural?
  9. Gait
  10. Describe stool/emesis
  11. Newly prescribed/altered medications?
  12. Last meal?
  13. BGL
  14. ECG/12 lead
  15. MEND
  16. Pupils
  17. Nystagmus?
  18. Vision Changes?
  19. Fever?
  20. Night sweats?
  21. Skin Color/temp
  22. MM (tongue)
  23. Cap refill
  24. Conjunctiva
  25. Orthostatic vitals
  26. Breath sounds
  27. Vagal stimulus?
  28. Cardiac or Stemi Alert?
  29. Sepsis Alert?
  30. ETOH/Substance involvement
  31. Interventions by agency
  32. How was patient moved to stretcher?

TASER DEPLOYMENT

  1. Location of probes
  2. # of shots, # of shocks, duration of shocks
  3. ETOH/Substance abuse involved?
  4. Probes removed? (impaled?)
  5. Trauma Assessment/other injuries?
  6. Blood loss?
  7. Interventions by agency
  8. Last Tetanus shot?

VAGINAL HEMORRHAGE

  1. Abdominal pain? (describe) PQRST
  2. Nausea/vomiting
  3. LMP
  4. Vertigo? Postural?
  5. Describe (clot, tissue, etc.)?
  6. Amount (estimate)? (number of pads, tampons over what time frame)
  7. LOC
  8. GCS
  9. Cap refill
  10. Conjunctiva
  11. Skin Color/Temp
  12. Orthostatic Vitals
  13. Interventions by FD/others
  14. How was patient moved to stretcher?

WEAKNESS/CVA

  1. SEE STROKE / CVA / TIA BENCHMARKS
  2. Dysphasic? Aphasic?
  3. Onset of signs/symptoms?
  4. Confusion, Hallucinations, Stupor, Delirium
  5. Vertigo, Focal weakness, Abnormal movements, slurred speech,
  6. Patient able to sit up without assistance?
  7. Respiratory Effort
  8. Lung Sounds
  9. New Meds?
  10. Headache?
  11. Vision changes or visual field issues?
  12. Eye deviation?
  13. Nystagmus?
  14. Pupils
  15. Cap refill
  16. Conjunctiva
  17. Fever?
  18. Rash?
  19. MEND
  20. EKG (12 Lead)
  21. MM (tongue)
  22. Skin color/Temp
  23. Recent illness, travel, visitors, etc.
  24. Orthostatic Vitals
  25. Nausea/vomit/diarrhea/constipation?
  26. BGL
  27. Sepsis Alert? Stroke? Cardiac?
  28. Interventions by agency
  29. How was patient moved to stretcher?

Extra Credit

  1. If hypocalcemia is suspected (patient with recent surgery on parathyroid) * (+) or (-) “Trousseaus” (contracture of forearm when B/P cuff is inflated on upper arm)
  2. “Homonymous Hemianopia” Loss of vision on one side in both visual fields (upper and lower) *Caused by a cerebral occlusion
  3. “Asterixis” non-rhythmic flapping of wrists and hands with arms extended and wrists hyper-flexed (hepatic encephalopathy) (in alcoholic patients)
  4. Acute narrow angle closure glaucoma: dilated, non-reactive pupils, eye pain, decreased visual acuity, blurred vision, pressure over eye, corneal clouding, halos, nausea/vomiting.*Caused by certain medications: * (ie, sympathomimetics, anticholinergics, antidepressants [SSRIs], anticonvulsants, sulfonamides, cocaine, botulinum toxin), dim light, and rapid correction of hyperglycemia. Trauma.
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