Detailed EMS Handover Notes - Prehospital Care Report (PCR)

DISPATCH INFORMATION Date: 1 November 2024 Incident #: 2024-EM-1123 Dispatch Time: 14:30 En Route Time: 14:35 At Scene Time: 14:45 Transport Begin Time: 15:00 At Destination Time: 15:20 Call Nature: Chest pain Location: 123 Main Street, Springfield Dispatch Priority: High PATIENT DEMOGRAPHICS Name: John Doe DOB: 15 March 1970 Gender: Male Address: 456 Elm Street, Springfield Phone: 555-1234 Insurance: HealthPlus ID: HP123456 Emergency Contact: Jane Doe, Wife, 555-5678 Primary Care Physician: Dr. Sarah Lee SCENE ASSESSMENT Scene Safety: Scene was secure with no immediate hazards. Number of Patients: 1 Mechanism of Injury/Nature of Illness: Suspected myocardial infarction Additional Resources Required: None Location of Patient: Patient was found sitting on a park bench, clutching his chest. PATIENT ASSESSMENT Chief Complaint: "I have severe chest pain and difficulty breathing." History (SAMPLE): Signs/Symptoms: Severe chest pain radiating to the left arm, shortness of breath, and sweating. Allergies: None known Medications: Aspirin, Lisinopril Past Medical History: Hypertension, Hyperlipidemia Last Oral Intake: Breakfast at 08:00 Events Leading: Patient was walking in the park when he suddenly experienced chest pain. PHYSICAL EXAMINATION General Appearance: Patient appeared diaphoretic and in distress. Mental Status: Alert and oriented to person, place, and time. HEENT: Pupils equal and reactive to light, no JVD. Respiratory: Tachypneic with bilateral wheezing. Cardiovascular: Irregular heart rhythm, S1 and S2 present. Abdomen: Soft, non-tender, no distension. Extremities: No edema, good capillary refill. Skin: Pale, cool, and clammy. Neurological: No focal deficits noted. Vital signs: Time: 14:50 BP: 160/95 HR: 110 RR: 24 SpO2: 92% on room air Temp: 37.0°C Pain (0–10): 8 GCS: 15 INTERVENTIONS Oxygen therapy: 4 L/min via nasal cannula started at 14:55 Position: Patient placed in semi-Fowler's position Medication: Aspirin 325 mg chewed at 14:55 IV Access: 18-gauge in left antecubital fossa at 15:00 Continuous cardiac monitoring: Sinus tachycardia with occasional PVCs TREATMENT RESPONSE Patient reported slight relief in chest pain after aspirin administration. Oxygen therapy improved SpO2 to 96%. TRANSPORT/HANDOFF INFORMATION Transport Decision: Emergency transport Transport Position: Semi-Fowler's position Report Given To: Dr. Emily Carter, Emergency Department Care Transferred: 15:25 Additional Notes: Patient's wife was informed and followed the ambulance to the hospital. SIGNATURES EMS Provider: Jane Smith, EMT-P ID: 7890 Patient Consent: John Doe Date/Time Completed: 1 November 2024, 15:30