Dispatch & Arrival
On 1 November 2024, at 14:30, EMS was dispatched to 123 Main Street following a report of a 45-year-old male experiencing chest pain. Upon arrival at 14:45, the scene was calm with the patient seated on a chair, appearing pale and diaphoretic. Bystanders included the patient's wife and a neighbour. Initial safety assessment revealed no immediate hazards.
Patient History
The patient reported sudden onset of severe chest pain radiating to the left arm, beginning approximately 30 minutes prior to EMS arrival. He has a history of hypertension and hyperlipidemia, for which he takes lisinopril and atorvastatin. He is compliant with his medications and has no known allergies. The patient had a light breakfast earlier in the day.
Assessment Findings
Upon assessment, the patient was alert and oriented, with a Glasgow Coma Scale score of 15. Vital signs were as follows: blood pressure 160/95 mmHg, heart rate 110 bpm, respiratory rate 22 breaths per minute, and oxygen saturation 94% on room air. Pupils were equal and reactive to light. The patient reported a pain score of 8/10.
Interventions & Treatment
Oxygen was administered via nasal cannula at 4 L/min, and aspirin 325 mg was given orally. An IV line was established in the left antecubital fossa, and nitroglycerin 0.4 mg was administered sublingually. The patient's pain decreased to a score of 5/10 following these interventions.
Transport & Monitoring
Transport was initiated at 15:00 with the patient positioned semi-Fowler's on the stretcher. Continuous cardiac monitoring was maintained, and vital signs were reassessed every 5 minutes. The patient's condition remained stable en route to the hospital.
Hospital Handover
The patient arrived at City Hospital at 15:20 and was handed over to Nurse Jane Smith in the emergency department. The handoff was confirmed, and care was officially transferred at 15:25. The EMS report was faxed to the hospital, and all equipment was accounted for before concluding the call.
Additional Notes
The patient was cooperative throughout the process. The home environment was noted to be clean and safe, with no apparent risk factors contributing to the incident.
Dispatch & Arrival
[insert a chronological narrative of the dispatch event and crewβs arrival at the scene] (write in paragraph format using full sentences; include the dispatch time, address or location of incident, what was reported en route, description of the scene on arrival, patientβs presentation, initial observations, presence of bystanders or family, and any immediate safety or hazard assessments; only include information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Patient History
[insert a narrative summary of the patient's medical history and reported events leading to the current episode] (write in paragraph format using full sentences; include patientβs reported or observed reason for incident, any relevant past medical history, current medications, medication compliance, allergies, recent oral intake, and any events or symptoms leading to EMS being called; only include information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Assessment Findings
[insert findings from the initial physical and cognitive assessment of the patient] (write in paragraph format using full sentences; include any injuries, vital signs, level of consciousness, pupil reactivity, pain scores, neurological responses, observed or reported discomfort, musculoskeletal assessment findings, and respiratory or cardiovascular status; only include information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Interventions & Treatment
[insert a narrative summary of the interventions provided during care] (write in paragraph format using full sentences; include any immobilisation procedures, wound care, monitoring applied, medications administered, IV access placement, and post-intervention evaluations such as ECG or pain reassessment; only include information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Transport & Monitoring
[insert a chronological account of patient care during transport] (write in paragraph format using full sentences; include transport initiation time, patient position, clinical monitoring throughout transport, any secondary assessments or observations made en route, changes in condition, and additional vital signs taken; only include information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Hospital Handover
[insert a narrative summary of the hospital arrival and patient handoff process] (write in paragraph format using full sentences; include the name of the receiving facility, time of arrival, name or role of the nurse or clinician receiving the report, handoff confirmation, transfer of care time, documentation processes such as faxing the report, and actions taken to secure EMS equipment and conclude the call; only include information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Additional Notes
[insert any final comments or situational context that influenced care or risk assessment] (write in paragraph format using full sentences; include comments on patient cooperation, scene safety follow-up, home status, contributing risk factors, or any care considerations not captured in earlier sections; only include information if it 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 included 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.)
