Emergency Medical Services Notes (EMS Report)

Section 1. Patient Information Name: John Doe Date of Birth: 1985-06-15 Age: 39 Gender: Male Chief complaint: Severe chest pain Section 2. Dispatch Details Dispatch time: 14:30 Incident location: 123 Main Street, Springfield Dispatch or vehicle number: EMS-456 Emergency service officer name: Officer Jane Smith Initial report: Patient experiencing severe chest pain and shortness of breath. Section 3. Arrival Emergency medical dispatch performed: Yes, bystander CPR was initiated by a passerby. If yes, elaborate on medical dispatch details performed: Bystander performed CPR until EMS arrival. Chief complaint (reported by dispatch): Severe chest pain Initial assessment: Patient is conscious but in distress, with labored breathing and clutching chest. Section 4. Health Status Previous medical history: Hypertension, hyperlipidemia Medications: Lisinopril, Atorvastatin Allergies (if known): None Patient chief complaint: Severe chest pain radiating to the left arm Additional notes: Patient reports onset of pain 30 minutes prior to EMS arrival. Section 5. Vital Signs Level of Consciousness (L.O.C): Alert Speech: Coherent Skin: Cold Colour: Pale Respiration: Rapid and shallow Pulse (bpm): 110, irregular Blood Pressure: 150/90 Additional notes/checks: Patient appears diaphoretic. Section 6. Physical Examination Injury Present: No Section 7. Additional notes Additional notes and procedures: Administered aspirin and nitroglycerin en route to hospital. Notified receiving hospital of incoming patient with suspected myocardial infarction. Transport changes: None Signature: Officer Jane Smith Officer name: Officer Jane Smith Date (yyyy/mm/dd): 2024/11/01