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					PRIVATE EMS                                                                          PATIENT CARE
                                                                                     REPORT
123 Main St.
Page ____of ____
Worcester, MA
SERVICE FROM                                                               CITY:          □ BED CONFINED BEFORE/AFTER ARRIVAL
ADDRESS:                                                                                  X□ TRANS. NEAREST APPROPRIATE FACILITY
                      175 WEST MAIN STREET                                                □ TRANS. FOR BENEFIT OF PREFERRED M.D.
                                                                           CITY:          □ TRANS. FOR REQUEST OF FAMILY:_____________
SERVICE TO:
                                                                                          □ TRANS. FOR CARE OF SPECIALIST OR AVAILABILITY
                  COUNTY GENERAL HOSPITAL                                                 OF SPECIAL EQUIP.

                                                PATIENT INFORMATION
PATIENT NAME (LAST, FIRST) BESSIE CRANDELL

SEX F     DATE OF BIRTH \11/19/1915                 AGE 95           SOCIAL SECURITY NUMBER
                                /   /
PATIENT ADDRESS 175 WEST MAIN STREET                  WORCESTER MA

HOME TELEPHONE
(    )
EMPLOYER N/A                                                       TELEPHONE                                    WORKER’S COMP
                                                                   (     )                                        YES       NO
RESPONSIBLE PARTY OR NEXT OF KIN             RELATIONSHIP (CIRCLE ONE)                                    TELEPHONE
UNKNOWN                                      POLICY HOLDER SPOUSE   GUARDIAN   SON   DAUGHTER   OTHER     (     )
STREET ADDRESS                                                CITY                              STATE             ZIP

INSURANCE COMPANY                             MEDICAID                                          MEDICARE

STREET ADDRESS                                                CITY                              STATE                 ZIP

SUBSCRIBER                               POLICY NUMBER                                   GROUP NUMBER

SECONDARY INSURANCE COMPANY                                          POLICY NUMBER

STREET ADDRESS                                                CITY                                            STATE                ZIP

                                                       NARRATIVE
95 YEAR OLD FEMALE CALLED 911 FOR CHEST PAIN AND SOB. UPON ARRIVAL, COMPLAINED OF PROFOUND
SOB. 100% FM O2 APPLIED, PULSE OX 80%. MONITOR SHOWED SINUS TACH AT 180 BPM WITH
MULTIPLE PVCS AND RUNDS OF VTACH. LIDOCAINE 50 MG BOLUS TIME TWO. DRIP AT 2 MG PER MINUTE
BEGUN.
DURING TRANSPORT, PATIENT DEVELOPED PULSELESS VT, THEN VF. COUNTERSHOCK TIMES
2, CPR BEGUN, FLUIDS WIDE OPEN. PULSE RESTORED.




ATTENDANT SIGNATURE         EMPLOYEE #       PARAMEDIC       ATTENDANT SIGNATURE                   EMPLOYEE #         PARAMEDIC
                                             EMT                                                                      EMT
ATTENDANT SIGNATURE         EMPLOYEE #       PARAMEDIC       DRIVER SIGNATURE                      EMPLOYEE #         PARAMEDIC
                                                              EMT                                                                EMT
 PM HX:                                                                                         ALLERGIES

 MEDS:

                                                                       VITAL SIGNS
TIME      BLOOD          PULSE   RESP           N-NORMAL            CARDIAC MONITOR      SAO2       O2       BGL        PUPILS     COMA SCALE
         PRESSURE         R/I    RATE           S-SHALLOW                                          LPM
                                                  D-DEEP                                                                R    L     E   V    M
 8A       70/P           180     40         S                  ST W/ PVCS                80       100NR
                                                                                                  B
 81            O/                                              VT/VF
               /
               /
               /
                         IV LINES                                                       MEDS / ELECTRICAL RX
TIME    TYPE        SITE/ROUTE   SIZE      S/U     INITIALS     TIME      THERAPY     DOSAGE RATE/ROUTE JOULES          RESPONSE        INITIALS
 8A      16         R AC                                       8A       LIDO          50      BOLUS
         G
                                                               05       LIDO          50        BOLU
                                                                                                S
                                                                                                          400    SINUS TACH

TOTAL AMT IV FLUIDS INFUSED      PT. KG.


               AIRWAY PROCEDURES
TIME    SIZE          ORAL       NASAL     S/U     INITIALS




   CONTROLLED SUBSTANCES WASTED
  DRUG  QUANTITY    WITNESSED BY:

                                                               PROCEDURE ORDERED BY DR.:                    FACILITY:

				
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posted:9/26/2012
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