1. Student CLINICAL Patient Care Report ST LOUIS PUBLIC SCHOOLS Fire & EMS ACADEMY
STUDENT INFORMATION
Student Name (Last, First, MI) Clinical Site
Age Gender Weight Room No.
PATIENT INFORMATION
Chief Complaint:
General Impression:
Abdominal Pain/ Problems
Nausea / Vomiting
Shock
Airway Obstruction
Poisoning/Drug Ingestion
Stroke / CVA
Pregnancy
Syncope / Fainting
Allergic Reaction
Trauma (fill in outline on page 2)
Altered level of Consciousness
Psychiatric Disorder
Vaginal Hemorrhage
Chest Pain/ Problems
Respiratory Problems
Other
(Specify)
Diabetic Problems
Seizure
CLINICAL INFORMATION (continue in narrative section)
Signs/Symptoms
Allergies
Medications
Prior Medical History
Last Oral Intake (What, How much, When)
Last Bowel Movement
Last Menstrual cycle
Events leading to this episode
VITAL SIGNS
Blood Sugar
Glasgow Coma Scale
Trauma Score
Time
B / P
Pulse
Resp
Temp
SpO2

2. Gateway EMS Program Patient Care Report, Page 2
Glasgow Coma Scale
Eye Opening
Verbal Response
Motor Response
4-Spontaneous
5-Oriented & converses
6-Obeys verbal commands
3-To verbal Commands
4-Disoriented & converses
5-Localizes pain
2-To pain
3-Inappropriate words
4-Withdraws from pain
1-No response
2-Inconprehensible sounds
3-Decorticate to pain
2-Decerebate to pain
Revised Trauma Scale
Glasgow Coma Score (GCS)
Systolic Blood Pressure
Respiratory Rate
4=(13-15)
4=(>89)
4=(10-29)
3=(9-12)
3=(76-89)
3=(>29)
2=(6-8)
2=(50-75)
2=(6-9)
1=(4-5)
1=(1-49)
1=(1-5)
0=(3)
0=(0)

3. PROCEDURES NARRATIVE TEAM INFORMATION
Gateway EMS Program Patient Care Report, Page 3
EXPOSURE INFORMATION
Significant Exposure
Exposure Precautions
Airborne Exposure
Needlestick
All Precautions
Hepafilter
Blood to Eyes
Other Body Fluids
Gloves
None
Blood to Mouth
Saliva to eyes
Gloves/Mask
Goggles
Not Applicable
Blood to Open Wound
Saliva to Mouth
Mask
Other
Mouth to Mouth
Unknown
Mask/Goggles
Multiple Exposures
Not applicable
PROCEDURES
Bleeding Control
Assisted Ventilation (BVM/Pocket Mask)
Cervical Collar
Oxygen by cannula
Oral Airway
Long Spine Board
Oxygen by mask
Nasal Airway
Short Spine Board /KED
Pulse Oximeter
Dual Lumen Airway
Extremity Splint
Glucometer
Suction
Traction Splint
Burn Care
ECG Monitoring
Other
External Defibrillation
NARRATIVE
Include Vital signs (x13), OPQRST information, pain level, medications/treatment given, patient response to meds/treatment, Head-to-Toe exam, any other pertinent/relevant information.
PATIENT DISPOSITION
TEAM INFORMATION
(Printed Name, Signature and date)
Student:
Preceptor/Supervisor: