Emergency Medical Services Notes (EMS Report)

Section 1. Patient Information Name: [insert patient name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Date of Birth: [insert patient date of birth] (only include date of birth if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Age: [insert patient age] (only include age if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Gender: [insert patient gender] (only include gender if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Chief complaint: [insert primary issue or complaint reported by or observed in the patient] (write as a brief phrase or sentence; only include if a chief complaint has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Section 2. Dispatch Details Dispatch time: [insert time of dispatch] (only include dispatch time if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Incident location: [insert location of incident] (only include location if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Dispatch or vehicle number: [insert unit or vehicle ID number] (only include if number has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Emergency service officer name: [insert officer name] (only include if name has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Initial report: [insert details of initial report as received via dispatch] (write in sentence format; only include if initial report has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Section 3. Arrival Emergency medical dispatch performed: [insert status of pre-arrival or on-arrival interventions] (state whether performed and by whom; only include if emergency dispatch information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) If yes, elaborate on medical dispatch details performed: [insert description of what actions were taken prior to arrival or by bystanders] (write in brief sentences; only include if medical dispatch actions have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Chief complaint (reported by dispatch): [insert chief complaint as received from dispatch] (write as a brief phrase or sentence; only include if dispatch-reported complaint has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Initial assessment: [insert summary of initial assessment conducted upon arrival] (write in sentence format; only include if initial assessment has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Section 4. Health Status Previous medical history: [insert patient medical history] (write in short form using phrases or full sentence; only include if previous medical history has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Medications: [insert list of current medications] (list or describe medications in-line; only include if medications have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Allergies (if known): [insert known allergies] (only include if allergies have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Patient chief complaint: [insert primary issue or reason for EMS attendance] (write in sentence format; only include if patient complaint has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Additional notes: [insert any further relevant health notes observed or reported] (write in brief paragraph format; only include if additional notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Section 5. Vital Signs Level of Consciousness (L.O.C): [insert patient’s LOC status across Alert, Voice, Pain, Unresponsive categories] (write responses inline; only include if LOC data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Speech: [insert status across Coherent, Incoherent, Slurred, Silent] (write responses inline; only include if speech status has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Skin: [insert condition of skin: Normal, Damp, Hot, Cold] (write responses inline; only include if skin condition has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Colour: [insert colour observations: Normal, Cyanotic, Flushed, Pale] (write responses inline; only include if colour observation has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Respiration: [insert status of respiration] (write response inline with description; only include if respiratory data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Pulse (bpm): [insert heart rate status] (write response inline with description; only include if pulse data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Blood Pressure: [insert status or measurement] (write in line format; only include if blood pressure data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Additional notes/checks: [insert any additional observations relevant to vital signs] (write in sentence format; only include if any further vital notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Section 6. Physical Examination Injury Present: [insert Yes or No based on exam] (only include if presence or absence of injury has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Section 6a. Injury Cause of injury: [insert cause if applicable] (write in phrase format; only include if injury cause has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Injury Type: [insert injury type classification] (write as Burn, Blunt, Penetration, Other or Unknown; only include if injury type has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Additional notes: [insert any other injury-related notes] (write in full sentence format; only include if additional injury notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Section 6b. Substance Use Indicators: [insert substance-related indicators observed] (describe observed indicators such as smell of alcohol, slurred speech, etc.; only include if substance use indicators have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Additional notes (i.e., substance details): [insert additional substance-related notes] (write in sentence format; only include if substance-related notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Section 7. Additional notes Additional notes and procedures: [insert summary of procedures, notable observations, or medical decisions taken during or after the call] (write in paragraph format; only include if procedures or additional notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Transport changes: [insert any changes in transport plan or method] (write in sentence format; only include if transport changes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Signature: [insert provider signature if required] (only include if signature is required and has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Officer name: [insert officer full name] (only include if officer name has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Date (yyyy/mm/dd): [insert date of documentation] (only include if date has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)