BLS RUN BASIC

The below narrative is a part of an electronic patient care report (“ePCR”) which has other parts which may include but not be limited to attachments and sections for run information, patient identifying information, patient health history, patient assessment, treatment and the names of the persons other than the primary technician who were present and/or who played a role in the transport of the patient. The narrative is intended to be considered and construed in light of any information recorded in the other parts of the ePCR.  The narrative was prepared close in time to the events of the run, however time constraints and/or other factors may have resulted in some information or facts being Inadvertently omitted from the narrative or other sections of the ePCR. Nothing in the narrative or any other part of the ePCR shall be construed as a representation that all possibly relevant information and facts have been recorded, or to preclude the provision at a later date by members of the crew of additional relevant information or facts which may have been omitted due to time constraints or other factors.

***HISTORY***

The events leading up to the ambulance being called were reported to be []

***ASSESSMENT***

Except as specifically noted elsewhere in this ePCR, there were no special isolation precautions reported to crew, and on initial contact and throughout transport the standard precautions were followed with the primary technician and the driver wearing personal protective equipment consisting of gloves. Other individuals present with patient on initial contact were the driver.

On initial contact by primary technician patient was wearing [] and found []. There were [] medical devices observed and/or reported consisting of [].

General first impression of primary technician was that patient was [] with no obvious immediate life threats observed.

Primary technician introduced himself to patient by name, stated his qualification as an EMT, and stated he was there to transport patient by ambulance. Pt was questioned and was AOx[] Consent was received from [] for EMTs to perform further medical assessment of patient.

Pt was talking with complete sentences, there were no foreign bodies observed blocking airway, and there were no sounds heard indicating any airway blockage (e.g. snoring respirations, stridor). The mouth and pharynx were visually observed and appeared patent. There was no apparent immediate need for suction or for an airway adjunct.

Breathing was observed from chest rise to be a regular rate, rhythm and tidal volume and pt denied any difficulties breathing. There were no reports or observations of any respiratory issues except as may be specifically noted elsewhere elsewhere in this ePCR.

There were no obvious signs of active bleeding and the patient’s measured heart rate had a regular rhythm and rate except as may be reported elsewhere in this ePCR. The visible skin of patient appeared intact, was warm, dry and a normal color for the patient except as may be specifically noted elsewhere in this ePCR. The patient denied and/or there were no reports of any chest pain.

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No abnormal posturing was observed. Pt denied, and/or there were no reports of, any headache, dizziness, blurred vision, numbness, tingling, or nausea. Pt could move those fingers and toes that were visible except as may be specifically noted elsewhere in this ePCR. No weakness of either side of pt body was observed or reported except as may be specifically noted elsewhere in this ePCR report.

Based on the assessment as reported above and elsewhere in relevant sections of this ePCR, along with the information received by EMT from any others present on scene and/or any medical records reviewed, the provider impression of primary technician was [] ([]).

Based on the primary impression of the primary technician, and in accordance with any requested and attached ALS assessment, it was determined that the patient’s medical condition was such that the patient could be safely transported from the pickup location to the destination by the BLS ambulance and crew.

***TREATMENT***

Except as specifically noted herein, the patient was assessed and treated within the scope of practice for an EMT-B at PRN ambulance in accordance with LA County treatment protocol …..and any guidelines or protocols referenced therein (attached hereto) and as specifically reported elsewhere in this ePCR.

There were no other medical treatments administered during the call, except for …..

***TRANSPORT***

After the primary assessment was performed, history obtained, and baseline vitals measured as reported elsewhere in this ePCR, the pt was positioned on ambulance gurney by EMTs. The gurney side rails were raised, and the patient was secured on gurney with all straps unless otherwise noted elsewhere. The pt was partially covered with a []. The gurney with the patient was then moved and loaded by EMTs into the ambulance without incidence.

During transport pt was . . . .  Pt was reassessed at least once every 15 minutes by primary technician, the documentation of which is recorded in the relevant sections and/or attachments of this electronic PCR.

***DELIVERY***

At the destination EMTs unloaded pt on gurney from ambulance without incident, and then moved pt on ambulance gurney to …. at destination. Pt physical and mental condition at time of transfer of care was unchanged materially from that at time of pt pick up, except as may be specifically noted elsewhere in this ePCR.  At the time of transfer patient was AOx…and GCS . . . .

At approximately the time of delivery the primary technician gave a complete verbal report and all transfer papers to receiving staff identified elsewhere in this ePCR, and answered any questions posed by staff with all information known and available to primary technician.

***EXCEPTIONS***

There were no other events.