STUDENT INFORMATION Student Name (Last, First, MI) Clinical Site

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Trauma Patient Assessment

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Presentation transcript:

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

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)

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: