Student Patient Care Report – Emergency Medical Services University, LLC

Student Patient Care Report

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Date of Incident

Incident Location

Time History Right

Times

Military Time Only (example: 1523)

Dispatched

Responding

On Scene

Clearing

Provider Information

Student Name

First

Last

Student ID

EMT student ID's are usually in this format: 123456FT-01. If you do not know your Student ID, please ontact Customer Service.

Preceptor Name

First

Last

Preceptor Certification Number

Patient Information

Gender

Medications

Age

Past Medical History

Chief Complaint

Onset Time

Allergies

Patient Vital Signs (Set One)

Time

Military Time Only (example: 1523)

LOC

Respiratory Rate

Respiratory Quality

Pulse Rate

Pulse Quality

SaO2

Glucose

Blood Pressure

Left Pupil

Right Pupil

Patient Vital Signs (Set Two)

Time

Military Time Only (example: 1523)

LOC

Respiratory Rate

Respiratory Quality

Pulse Rate

Pulse Quality

SaO2

Glucose

Blood Pressure

Left Pupil

Right Pupil

Patient Vital Signs (Set Three)

Time

Military Time Only (example: 1523)

LOC

Respiratory Rate

Respiratory Quality

Pulse Rate

Pulse Quality

SaO2

Glucose

Blood Pressure

Left Pupil

Right Pupil

Clinical Findings

Skin

Head/Face

Neck

Chest

Abdomen

Pelvis

Extremeties

Posterier

Intervention 1

Time

Military Time Only (example: 1523)

Response

Intervention 2

Time

Military Time Only (example: 1523)

Response

Intervention 3

Time

Military Time Only (example: 1523)

Response

Intervention 4

Time

Military Time Only (example: 1523)

Response

Intervention 5

Time

Military Time Only (example: 1523)

Response

Intervention 6

Time

Military Time Only (example: 1523)

Response

Treatment Narrative

Must be at least 250 characters.

Survey (Optional)

Disposition

Care Refused

Transportation Refused

Care Transferred to Other Agency

Name of Agency

Time Care Transferred

Military Time Only (example: 1523)

Signature of Student

Clear Signature

EMS University

Times

Provider Information

Patient Information

Patient Vital Signs (Set One)

Patient Vital Signs (Set Two)

Patient Vital Signs (Set Three)

Clinical Findings

Survey (Optional)

Disposition

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