MUHLENBERG COLLEGE EMS

Patient Care Report

,, , , DATE ~FCALL , CALL REeD

[J]JTIJ

, ,
I
, ., . I
LIGHTS
USED MILEAGE
ARRIVED
o ~gENE START
FROM

D o ~~~~E END
SCENE
ARRIVED
I-+---t-----j----j

AT HaSP f-+--+-+----1
NAME HOME ADDRESS
COMPLETE IL---'-------'_-'------!
HOME PHONE CAMPUS EXT CAMPUS ADDRESS
CARE IN PROGRESS ON ARRIVAL
DISPATCH INFO CALL LOCATION
ONONE OPD/FD 0 OTHER EMS

S OCITIZEN 0 OTHER HP
[JMVC o Sports o Fall of __ feet ONone o Machinery A
G
0
0 E 0 o
o Struck by vehicle o Unarmed assualt OOthe, E B X M F
MCPD Officer(s) on scene
SUBJECTIVE STATEMENT HEALTH PROFESSIONAL CONTACTED

Other Assisting Units

OUnremarkabie EYES VERBAL MOTOR

Cool 0 Pale @Spontan. @Oriented G)None @Obeys Comm. (glPain-Extends
Warm 0 Cyanotic @ToVoice @Confused @Pain-Local G)None
Moist 0 Flushed (glTo Pain @Inapprop. @Pain-Withdr.
Dry 0 Jaundiced G)None (glGarbled @Pain-Flexion
OUnremarkable EYES VERBAL MOTOR
Cool 0 Pale @Spontan. @Oriented G)None @Obeys Comm. @Pain-Extends
Warm 0 Cyanotic @ToVoice @Confused @Pain-Local G)None
Moist 0 Flushed (glToPain @Inapprop. @Pain-Withdr.
=- -----'=...L-'=_D_ry"----'O Jaundiced G)None @Garbled @Pain-Flexion
CURRENT MEDS. (LIST)

OChest Pain OVomiting OPain _ _ _ []Denied OCVA/TIA OSeizure

ODiff Breathing [J 0 iah rrhea OChoking OMI o Behavioral o Hypertension
OWeakness o Headache OBurn [ITI% []CHF o Diabetes OAsthma
o Dizziness OSeizure OGenerallliness OAngina OSyncope OMigraine

ONausea OBehavioral 0 OOther

OBJECTIVE PHYSICAL ASSESSMENT

E----------­
TREATMENT GIVEN

o Moved on stairchair
o Walked to First Response Unit
BLEEDING
LACERATION
o
o Airway cleared ABRASION
o
o
rn

S.HH.
o Oral/Nasal Airway CONTUSION

o Oxygen Administered @ L.P.M., Method _

AVULSION o ST. LUKE'S I

o Suction Used NUMBNESS o MCHC

Q OTHER
o C.P.R. in progress upon arrival by: 0 Citizen 0 PD/FD/Other CFR 0 Other
o C.P.R. started @ Time [ITO Time from arrest until CPR [=rrJ Minutes DEFORMITY

o Automatic Defibrillation No. of times 0 By: SWELLING

AMPUTATION

o Bleeding/Hemorrage Controlled (Method) _

BURN

o Spinal Immobilization Neck & Back PAIN

o Limb Immobilized by 0 Fixation 0 Traction TENDER

o Other _

C IN CHARGE o DRIVER NAME

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W EMT#
 MUHLENBERG COLLEGE EMS
,, , Patient Care Report
ITIIIIJ
,
,,
,,
DATE OF CALL
,,
, CALL REC'D

ARRIVED
NAME ADDRESS

HOME PHONE CAMPUS EXT CAMPUS ADDRESS FROM

SCENE
DISPATCH INFO CALL LOCATION

ARRIVED
CALL REC'D AS A
AT HOSP

o EMERGENCY
G L--'_---'------'------.J

DNON

EMERGENCY
COMPLETE
Df------------------------1
o STANDBY F
SUBJECTIVE ASSESSMENT

HEALTH SERVICE NOTIFIED? HEALTH PROFESSIONAL ON CALL

DMVA (,/ seat belt used_) o Fall of __ feet DGSW DMachinery
DStruck by vehicle DUnarmed assualt DKnife 0 YES 0 NO 0 I ------j

PRESENTING PROBLEM
If more than one checked, circle primary
o Allergic Reaction 0 Unresponsive 0 Shock 0 Major Trauma 0 OB/GYN
0 Syncope 0 Seizure 0 Head Injury 0 Trauma-Blunt [J Burns
o Airway Obstruction
o Respiratory Arrest
o Stroke/CVA 0 Behavioral Disorder 0 Spinal Injury 0 Trauma-Penetrating Environmental
0 General Illness/Malaise 0 Substance Abuse (Potential) [] Fracture/Dislocation 0 Soft Tissue InJury Heat
o Respiratory Distress
o Cardiac Related (Potential)
o Gastro-Intestinal Distress 0 Poisoning (Accidental) 0 Amputation o Bleeding/Hemorrhage Cold
0 Hazardous Materials
o Cardiac Arrest

Rate: o Alert 0 Normal 0 DUnremarkable

DRegular o Voice 0 Dilated 0 0 Cool o Pale
0 0 0 Warm 0 Cyanotic
o Hypertension o Stroke DShallow DRegular o Pain 0
Constricted
Sluggish 0 0 Moisto Flushed
o Seizures o Diabetes DLabored Dlrregular o Unresp. 0 No-Reaction 0 0 Dry o Jaundiced
Rate: Rate: o Alert 0 Normal 0 DUnremarkable
o Cardiac o Voice 0 0 Cool o Pale
o COPD DRegular
0
Dilated
Constricted 0
0
0 0
DShallow DRegular o Pain 0 Sluggish 0 [J
Warm
MOist [J
Cyanotic
Flushed
DLabored o Irregular o Unresp 0 No-Reaction 0 0 Dry o Jaundiced

OBJECTIVE PHYSICAL ASSESSMENT

TREATMENT GIVEN

o Moved on stairchair 0 Medication Administered (see comments)

o Walked to First Response Unit 0 Bleeding/Hemorrage Controlled (Method) _
o Airway cleared 0 Spinal Immobilization Neck & Back
o Oral/Nasal Ainway
o Oxygen Administered @
o Suction Used
rn
LP.M., Method
0
0
0
Limb Immobilized by
Heat or cold applied (circle one)
Baby Delivered @ Time
0 Fixation

_
0 Traction

o C.PR. in progress upon arrival by: 0 Citizen 0 PD/FD/Other CFR 0 Other 0 Other _

o C.P.R. started @ Time [II[] Time from arrest until CPR [IIJ Minutes
o Automatic Defibrillation No. of times D By: 0 AEMS DCETRONIA DOTHER DNONE

TRANSPORTED TO: 0 L.V. CEDAR CREST 0 LV 17TH ST 0 SACRED HEART 0 HEALTH CENTER 0 OTHER:
C IN CHARGE DRIVER NAME

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 TYPICAL VITAL SIGNS RANGES
ADULT 9
THE RULE OF NINES
Estimation of Burned
BLOOD PRESSURE 90 - 140 SYSTOLIC Body Surface
60 - 90 DIASTOLIC
(PERCENT)
PULSE 60 - 100 BEATS/MINUTE
i 18 (Front) i

RESPIRATIONS 12 - 20 BREATHS/MINUTE 18 (Back)i'

18
9 9
CHILD
BLOOD PRESSURE 80 - 110 SYSTOLIC
18
9 (Front)
PULSE 80 - 100 BEATS/MINUTE 18
18· 18 i (Back)
RESPI RATIONS 15 - 30 BREATHS/MINUTE

14
INFANT (Newborn to 1 Yr.)
BLOOD PRESSURE 2X Patient's age + 80

PULSE 120 - 140 BEATS/MINUTE \ i

,/ I,
I. /

RESPIRATIONS 25 - 50 BREATHS/MINUTE
ADULT INFANT

I , have been advised that medical

assistance on my behalf is necessary and that refusal to accept pre-hospital
care and transporation to a healthcare facility may imperil my health or result
in death. I assume all risks, consequences and costs of my decision not to
accept pre-hospital care and/or transportation to a healthcare facility, and I
release Muhlenberg College, its officers, agents, licensed healthcare
professionals, employees and members of the Emergency Medical Services
'from any and all liability arising from my decision.

Name: _ Signature: - - - - - - - - - - - ­ Date: _

Witness: _ Signature: - - - - - - - - - - - - ­ Date: _

MUHLENBERG COLLEGE EMERGENCY MEDICAL SERVICES

EST. 1999

"Serving Our Campus With Pride"

9/04