$19.95
Description
These formats I developed over the course of 20-years as a paramedic. Responding in a busy EMS system with back to back calls, in rural areas that would take 45-minute to an hour to the hospital and in urban areas where you were at the hospital in minutes and then back onto the next call as soon as you had transferred the patient. Many times you didn’t have time to stop and write a complete report, so I used these cards to quickly record notes, and as reminders of things not to forget on the 5th call of the night at 3am! Then I would put the paperwork for each patient in a zip-lock bag at the end of the call. As soon as I was able I would open my “filing system” and complete the written report.
A complete field medical documentation kit for one responder managing up to four patients.
Reference cards (kept in kit):
- Clinical Reference (×1) — cranial nerve exam, muscle strength grading, peripheral pulses, pitting edema, and Glasgow Coma Score for rapid neurological assessment
- Medical Terminology (×1) — quick-reference definitions for speech, eye, ear, posture, chest, GI/GU, OB, and sleep findings
- Trauma Scoring & Vitals (×1) — Revised Trauma Score calculation table and normal vitals ranges for adult and pediatric patients
Patient cards (4 complete sets, one per patient):
- Patient Assessment Page 1 (×4) — demographics, scene, symptoms, allergies, medications, PMH, and a 10-row serial vitals log for tracking through extended care
- HPI / Subjective (×4) — full OPQRST and review of systems for capturing patient history
- Physical Exam — Trauma (×4) — DCAP-BTLS head-to-toe assessment by body region
- Injury / Findings Body Diagram (×4) — full-body anatomical diagram for marking injury location and recording findings
- TCCC Casualty Card (×4) — DD-1380 style casualty documentation that travels with the patient through evacuation
Semper Paratus, Semper Gumby.
