This is an example PCR narrative using the Pre-SOAPeD format. Read about Pre-SOAPeD and EMS Documentation here.
Unit 292 responded emergent from headquarters for a reported Unconscious / Unresponsive at 123 Hogwartz Lane in the city of Outer Space with a full crew and without delay.
On arrival, found a 64 year Male patient weighing 136 KG. Chief complaint of Unresponsive.
-History of Present Illness-
Wife at scene states she heard a loud bang and found her husband on the ground verbally responsive. She states patient had felt agitated earlier today but had no other complaints before incident.
Medical/Surgical History: Diabetes Type II, EMP / Emphysema, PNA – Pneumonia, Sleep Apnea, Coronary Artery Disease, Hypertension / HTN, Smoking Tobacco, CAT – Cataract, CABG / STENT / Bypass Graft, Personal history of antineoplastic chemotherapy, Cholecystitis.
Environmental Allergies: Bee venom allergy. Medication Allergies: Augmentin.
Current Medications: metoprolol succinate, Fenofibrate, irbesartan, Isosorbide, Lasix, Humalog, Levemir, Lyrica, NITRO Nitroglycerin, Omeprazole, oxcarbazepine, Pristiq, Vitamin D, Vitamin E.
At 14:41, the patient was found. Initial assessment revealed the patient physically responsive and only able to make eye contact. Airway Patent, Lung sounds clear but diminished bilaterally, breathing pattern regular. Skin pale, cool diaphoretic, pulses weak, slow and irregular. GCS of 8 (Eye = 3, Verbal = 1, Motor= 4), Initial Vital signs, P – 32 II, R – 10.
Head to toe exam of patient revealed pupils regular round and reactive, HEENT CLR, negative jugular vein distention or tracheal deviation, abdomen distended non-rigid in all four quadrants, negative signs of trauma. Positive urinary incontinence noted.
Blood Glucose: 203; 3-Lead EKG showed complete heart block 30s-40s. SPO2 Initial 80% Room Air.
The field impression of the patient was [Cardiovascular] Cardiac Arrhythmia/Dysrhythmia.
Treatments were administered as follows:
14:42: Patient Assessment was performed successfully after 1 attempt.
14:42: Blood Glucose was performed successfully after 1 attempt.
14:43: Airway Opened was performed successfully after 1 attempt.
14:44: Oxygen 15 Liters Per Minute (LPM [gas]) NRB/PRB per Protocol (Standing Order). The patient’s response was Improved.
14:47: 3 Lead ECG Obtained was performed successfully after 1 attempt.
14:47: Pacing (External) was performed successfully after 1 attempt.
15:00: Medical Control Contacted was performed successfully after 1 attempt.
15:15: CPR – Manual was performed successfully after 1 attempt.
15:15: Bagged Ventilations (via Mask) was performed successfully after 1 attempt.
The patient was transported to Our Lady Of Holy Crap Hospital Emergent (Immediate Response).
-DELTA and HANDOFF-
Patient moved on stretcher, O2 administered, patient maintained airway and respiration on his own. Patient showed improvement with trans-cutaneous pacing (rate 60 bpm and 110 mA with mechanical capture) and was able to answer questions. Notification made to Medical Control resuscitation team requested.
Upon arrival at ED patient was moved to Cardiac Bed 1. Full report given to staff and in-hospital resuscitation begun immediately. EMS provider stayed and assisted transfer of pacing to hospital device when pulses were lost and CPR began in resuscitation bay. ROSC achieved shortly after and ED physician placed transvenous pacing device. Patient left in bed, with rails up, bed locked in staff presence.