Patient Care Report Outline  

 Subjective Data  

o Identification (ID)  

o Chief Complaint (CC)  

o Mechanism of Injury (MOI)  

o History of Present Illness (HPI)  

 Onset  

 Location, radiation  

 Duration  

 Character  

 Aggravating factors  

 Relieving Factors  

 Timing  

 Severity  

 Positives and Pertinent Negatives from review of system associated with CC  o Past Medical History (PMH)  

o Social History (SH)  

o Medications (Rx)  

o Allergies  

 Objective Data  

o Physical Exam  

 General (Gen) [ location/position of patient, +/ - acute distress ]  

 Vital Signs (VS) [Temp, HR, RR, BP, SpO2/SpCO]  

 Neurologic (Neuro)  

 Head/Ears/Nose/Throat/Neck (HEENT / Neck) [Normocephalic / atraumatic]   Cardiovascular (CV)  

 Skin findings  

 Pulse  

 Cardiac Auscultation  

 JVD -/+  

 EKG Interpretation  

 Pulmonary (Pulm)  

 Abdomen (Abd)  

 Extremities (Ext)  

 Musculoskeletal – Integument (MSI)  

 Labs  

 Assessment – Presumptive field diagnosis  

 Plan – Management plan for patient  

 Course - Include events, evaluation, interventions, response to interventions/ medications  during the prehospital/transport course 

Patient Care Report Outline  

---Sample Report---  

S: Patient is a 67 year old male who presents with a chief complaint of left hip pain. Patient  experienced a mechanical fall from a standing height. Pain began after fall, originates in left  hip and radiates down to the anterior aspect of the knee. Pain is sharp, stabbing, and  aggravated by movement. Rest and limitation of moment provides some minor relief. Patient  denies any LOC from fall. Patient is unable to stand or ambulate under their own power. 
PMH: HTN, CAD, MI with LAD stent (2008)  

Rx: ASA qd, Lisinopril qd, Lovastatin qd, Nitroglycerin PRN  

Allergies: Amoxicillin (anaphylaxis)  

O: Patient found supine on couch on scene. No acute distress.  

VS: P 76; R 16, BP 140/84, SpO2 98% (RA)  

NURO: AOx4, GSC 15, +CSM x4 extremities. 8/10 pain in left hip.  

HEENT: Normocephalic / atraumatic, PERRL 4mm, -spinal tenderness  

CV: Skin warm and dry, P76 normal rate and rhythm, +4 radial pulses, -JVD, -Peripheral  edema. EKG= NSR at 76bpm –acute ST / T changes. – cardiac ectopy.  

PULM: RR 16 with slight increase in work of breathing, patient is able to speak normally in full  sentences. Lung sounds clear bilaterally.  

ABD: Soft, non-tender, non-distended, non-pulsatile, no masses.  

EXT: No clubbing, cyanosis, edema, warm/well perfused.  

MSI: +swelling in left lateral pelvic area, pain on palpation. Instability in the area of iliac crest  LABS: capillary blood glucose 112mg/dl  

A: MSI injury, possible pelvic fracture.  

P: Immobilize pelvic region with SAM pelvic binding device. Establish PIV access in left AC 18g  with saline lock. Analgesia with fentanyl 50mcg IV, per protocol.  

C: +pedal pulses both lower extremities following pelvic binder application. Fentanyl with  good effect, no adverse effects, pain level decrease to 5/10. Vitals reassessed in route with no  notable changes. Patient transferred to Newport ED staff, handoff report given.