Dispatch / Response Responding unit / crew
Response mode
Select… Emergency response with warning devices Emergency response without warning devices Non-emergency response Standby / detail Interfacility transfer Mutual aid response
Dispatch nature / complaint
Response location
Response delay
Select… No delay Traffic delay Weather delay Railroad / roadway obstruction Staging for scene safety Awaiting law enforcement Unit availability delay Mechanical issue Other delay
Response delay details
Scene safety
Select… Scene safe / secured Potential hazard identified Scene not secure on arrival Law enforcement secured scene Staged until safe PPE / isolation precautions required Hazard mitigated before patient contact
Number of patients
Arrival / Initial Contact Patient location on arrival
Select… Residence - bed Residence - chair/couch Residence - floor Residence - bathroom Residence - other Vehicle Roadway Sidewalk / outdoors Public building Healthcare facility Workplace School Other
Patient position when found
Select… Standing Walking / ambulatory Sitting Supine Prone Lateral recumbent Semi-Fowler’s Fowler’s Trendelenburg On stretcher In wheelchair In vehicle Other
General appearance on first contact
Select… No obvious distress Mild distress Moderate distress Severe distress Critical / peri-arrest Cardiac arrest Unresponsive Agitated / combative Appears ill Appears injured Unable to determine
Arrival narrative / scene description
Chief Complaint Chief complaint / reason for EMS
Source of history
Reliability of history
Select… Good / reliable Limited by condition Limited by age/development Limited by language barrier Limited by altered mental status Limited by intoxication Limited by dementia/cognitive impairment Third-party history only Unable to obtain
History of Present Illness / Injury History / events leading to EMS activation
Onset
Provocation / palliation
Select… Nothing identified Worse with movement Worse with exertion Worse with inspiration Worse with palpation Worse with position Improves with rest Improves with position Improves with medication Other Unable to determine
Provocation / palliation details
Quality / character
Region / location
Radiation
Severity / pain score (0-10)
Time / duration / course
Pertinent negatives
SAMPLE / Relevant History Additional signs / symptoms
Allergies
Medications
Past medical / surgical history
Last oral intake
Last medications taken
Events preceding illness/injury
Primary Assessment
Neurologic Assessment GCS - Eye opening
Select… 4 - Spontaneous 3 - To verbal stimulus 2 - To painful stimulus 1 - None Unable to assess
GCS - Verbal response
Select… 5 - Oriented 4 - Confused 3 - Inappropriate words 2 - Incomprehensible sounds 1 - None Unable / non-testable
GCS - Motor response
Select… 6 - Obeys commands 5 - Localizes pain 4 - Withdraws from pain 3 - Abnormal flexion 2 - Extension 1 - None Unable / non-testable
GCS total
Formula: gcs_eye+gcs_verbal+gcs_motor
Stroke screen
Select… Not indicated / not performed Negative Positive Equivocal Unable to perform
Stroke screen details
Detailed Physical Assessment
Vital Signs / Diagnostics Heart rate (bpm)
Blood pressure
Respiratory rate
SpO₂ (%)
EtCO₂ (mmHg)
Temperature
Blood glucose
Cardiac rhythm / monitor interpretation
12-lead ECG interpretation
Additional assessment findings / pertinent negatives
Overall patient condition after assessment
Select… Stable Potentially unstable Unstable Critical Improved from initial contact Unchanged from initial contact Worsened from initial contact Unable to determine
Treatment / Interventions Medications administered
Procedure / intervention details
Response to treatment
Select… Not applicable / no treatment Improved Partially improved No change Worsened Adverse reaction Unable to determine
Treatment response details
Medical control
Select… Not contacted / not indicated Online medical control contacted Standing order / protocol used Medical control orders received Medical control unable to contact Other
Medical control details
Transport / Disposition Disposition
Select… Transported by this unit Transported by another EMS unit ALS intercept / transfer of care Air medical transport Patient refused transport Patient refused assessment and transport No patient found Cancelled prior to patient contact Lift assist / public assist only Dead on scene / no transport Other disposition
Movement to stretcher / ambulance
Select… Walked / ambulatory Wheelchair Stair chair Sheet / soft stretcher Scoop stretcher Long board / device used for movement Carried Assisted stand and pivot Patient remained in own wheelchair Other Not applicable
Position during transport
Select… Semi-Fowler’s Fowler’s Supine Prone Left lateral Right lateral Position of comfort Trendelenburg Seated Other Not transported
Stretcher restraint / safety
Select… Secured with stretcher straps per policy Seat-belted in captain’s chair / approved seat Pediatric restraint used Wheelchair secured Behavioral restraints used Not applicable
Destination
Destination selection
Select… Patient choice Closest appropriate facility Specialty destination Medical control direction Protocol / system plan Facility request / transfer destination Other
Transport priority
Select… Emergency / lights and siren Non-emergency No transport
En route care / reassessment
Condition on arrival
Select… Improved Unchanged Worsened Stable Unstable Critical Unable to determine Not transported
Transfer at destination
Select… Moved to ED bed Moved to hospital stretcher Moved to facility bed Ambulated to room Wheelchair transfer Care transferred without physical movement Other Not applicable
Care transferred to
Handoff / transfer-of-care details
Exceptions / Unusual Circumstances Exception details
Discussion
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