RC Health
Services
Emergency Medical Services Training
Hospital Form – Page 1 of ____
Student Name:
Date:
Course Level: EMT-B
EMT-I
EMT-P
Course Instructor:
Hospital:
Department:
Shift:
Total Hours:
Preceptor Name and Certification:
DSHS Number:
Patient Data: Gender
Male Female
Age:
Yr or Mo
Weight:
(kg)
Chief Complaint/Diagnosis:
MOI/NOI
Complaint
MOI/NOI
Complaint
Abdominal Pain
Allergic Reaction/Anaphylaxis
Animal Bite/Sting
Assault/Sexual Assault
Motor Vehicle Crash/Impact/Pedestrian
Respiratory Difficulty/Respiratory Arrest
Burns/Electrical Injury/Chemical Burn
Cardiac Arrest
Chest Pain/Cardiac Related Complaint
Choking/Aspiration/Foreign Body Obstruction
Diabetic/Endocrine
Drowning/Near Drowning
Fall
Neurological Emergency/Seizure/CVA/TIA
Possible Fracture/Dislocation/Sprain
Toxic Exposure/Poisoning/Overdose
Eye Injury
Infection/Sepsis
Pregnancy/Childbirth/Gynecological
Emotional Crisis/Suicide
Infectious Disease
Stabbing/Cutting/Shooting
Unconscious
Other:
Past Medical/Surgical History:
Current Medications:
Allergies:
Glasgow Coma Scale
Times
Eyes Verbal Motor
Pupils:
Equal:
Glucose:
Breath Sounds
Wheezes: L R
Upper Lower
Pain Scale
Temp:
Head
Face
Neck
Chest
Abdomen
Pelvis
Arms
Legs
Back/Spine
Student Signature:
Y
Resp
Vital Signs
Pulse
B/P
Color
Skin
Moisture
Temp.
N
Reactive: Y N
Round:
Y N
Size(mm): Lt.
Rt.
OB/Gyn. Grav.
Para.
Abor.
LNMP:
Clear: Y N
Equal: Y N
Absent: L R
Diminished: L R
Rales: Y N
Ronchi: L R
Stridor: Y N
Croup: Y N
Upper Lower
Upper Lower
Upper Lower
Upper Lower
Onset:
Severity (1-10)
Quality:
Radiation:
SaO2:
CO2:
ABD Sounds: LUQ( ) RUQ( ) LLQ( )RLQ( )
Assessment Findings
Assessment Findings Legend
T1 abrasion
M1 pain
T2 amputation
M2 nausea/vomiting
T3 avulsion
M3 abnormal sounds
T4 burn
M4 tenderness
T5 fracture/dislocation
M5 swelling
T6 laceration
M6 discharge
T7 puncture
M7 paralysis/weakness
T8 bleeding, external
M8 bleeding, internal
T9 other trauma
M9 other medical
Preceptor Signature:
Rev10/12
RC Health
Services
Emergency Medical Services Training
Hospital Form – Page 2 of ____
Student Name:
Date:
Differential Diagnosis
1.
2.
3.
Narrative
Describe the appropriate pre-hospital treatment in the field for this patient (to your level of class)
Briefly describe what you have learned from observing/treating this patient
O – Observed
Medical
Abdominal
CPR/Arrest
ET
Student Signature:
A – Attempted Procedure
Trauma
CVA/TIA
OB/Gyn
Meds
Patient Demographics
U - Unsuccessfully
P – Performed Procedure Successfully
Chest Pain
Diabetes
EKG
Allergy
Syncope/AMS
IV
Delivery
Psych
Suction
Respiratory
Other
Preceptor Signature:
Rev 10/12