Call / Arrival DO NOT enter patient name, DOB, address, phone number, MRN, insurance information, or other patient-identifying information into DocGen.
Provider level
Select… AEMT
Scene safety
Select… Scene safe Scene made safe Hazard present / mitigated Unable to fully assess
PPE / standard precautions
Select… Appropriate PPE used Additional PPE used No special PPE required Other
Dispatch / response reason
Patient position / location on arrival
General impression
Select… No apparent immediate distress Mild distress Moderate distress Severe distress Critical / peri-arrest Cardiac arrest
Responsiveness
Select… Alert Responds to verbal stimulus Responds to painful stimulus Unresponsive
Orientation
Select… A&O x4 A&O x3 A&O x2 A&O x1 Not oriented Unable to assess
Initial scene / presentation notes
Primary Assessment Airway
Select… Patent Patent with secretions Partially obstructed Completely obstructed Maintained with positioning Maintained with adjunct Unable to assess
Breathing effort
Select… Normal / unlabored Mildly increased Moderately labored Severely labored Agonal Apneic Unable to assess
Respiratory pattern
Select… Regular Irregular Tachypneic Bradypneic Shallow Deep Kussmaul-type Cheyne-Stokes-type Other / unable to assess
Circulation / perfusion
Select… Adequate Concern for poor perfusion Shock suspected Cardiac arrest Unable to assess
Radial pulse
Select… Strong Weak / thready Irregular Absent Not assessed
Major hemorrhage
Select… None identified Controlled before arrival Controlled by first responders Ongoing / difficult to control Unable to assess
Primary assessment notes
GCS Eyes
Select… 4 - Spontaneous 3 - To voice 2 - To pain 1 - None Unable to assess
GCS Verbal
Select… 5 - Oriented 4 - Confused 3 - Inappropriate words 2 - Incomprehensible sounds 1 - None Unable to assess
GCS Motor
Select… 6 - Obeys commands 5 - Localizes pain 4 - Withdraws from pain 3 - Flexion 2 - Extension 1 - None Unable to assess
GCS total
Pupils
Select… PERRL Equal / reactive Unequal Sluggish Fixed Pinpoint Dilated Not assessed
Stroke screening
Select… Negative Positive Equivocal Not indicated Unable to complete
Neurologic findings
History Chief complaint
Onset
Provocation / palliation
Quality
Region / radiation
Severity
Time / duration / progression
History details
Vital Signs / Monitoring Heart rate
Respiratory rate
Blood pressure
SpO₂
Temperature
Pain score / pain assessment
Blood glucose (if obtained / authorized)
Repeat vital signs / trend
EtCO₂ (if obtained)
ECG / 12-lead obtained
Select… Yes No Not indicated Unable to obtain
ECG / rhythm summary
Focused / Physical Assessment Head / face
Select… No abnormality identified Pain / tenderness Trauma / wound Swelling Bleeding Other abnormality Not assessed
Neck
Select… No abnormality identified Pain / tenderness JVD Tracheal deviation concern Swelling Other abnormality Not assessed
Chest
Select… No abnormality identified Pain / tenderness Trauma Unequal rise Crepitus Other abnormality Not assessed
Abdomen
Select… Soft / non-tender Tender Guarding Rigid Distended Mass / pulsation concern Other abnormality Not assessed
Pelvis
Select… No abnormality identified Pain / tenderness Instability concern Other abnormality Not assessed
Back / spine
Select… No abnormality identified Pain / tenderness Deformity / step-off concern Other abnormality Not assessed
Upper extremities
Select… No abnormality identified Pain / tenderness Deformity Swelling Wound Neurovascular deficit concern Other abnormality Not assessed
Lower extremities
Select… No abnormality identified Pain / tenderness Deformity Swelling Wound Edema Neurovascular deficit concern Other abnormality Not assessed
Additional exam findings
Select only findings actually assessed or reported. Use 'Not assessed' when a system was not reviewed.
Additional ROS details / pertinent negatives
Treatments / Interventions Treatment details
Response to care
Select… Improved Unchanged Worsened Mixed response Not reassessed / care immediately transferred Unable to assess
Reassessment findings
Vascular access
Select… Not attempted IV established IO established Attempted but unsuccessful Not indicated
IV / IO site
Catheter / device size
Number of attempts
Fluids administered
AEMT medications
Advanced airway / respiratory support details
Disposition Final disposition
Select… Care transferred to transporting EMS service Patient refused further EMS care / transport
Transfer of Care - Complete when care is transferred Transporting EMS service / agency
Transporting unit
Level of provider assuming care
Select… EMR EMT AEMT Paramedic RN Other Unknown
Patient condition at transfer
Select… Improved Unchanged Worsened Critical Other
Approximate transfer-of-care time
First-response crew assisted after transfer
Select… No Yes - assisted transport crew before departure Yes - accompanied transport crew Not applicable
Transfer-of-care notes
Document capacity and informed decision-making, not merely orientation. Follow current Vermont protocols, agency policy, medical direction, and applicable law.
Patient able to communicate a consistent choice
Select… Yes No Unclear / unable to determine Not assessed
Patient demonstrated understanding of relevant information
Select… Yes No Unclear / unable to determine Not assessed
Patient demonstrated appreciation of potential consequences
Select… Yes No Unclear / unable to determine Not assessed
Patient demonstrated ability to reason about options
Select… Yes No Unclear / unable to determine Not assessed
Patient verbalized understanding
Select… Yes No Unclear / unable to assess
Patient continued to refuse after discussion
Select… Yes No - accepted care / transport Unable to determine
Medical control contacted
Select… Yes No Not required by protocol / policy Unable to contact
Transporting EMS service present for refusal
Select… Yes No Unknown / not applicable
Refusal witnessed
Select… Yes No Not required / unavailable
Witness / role
Refusal / capacity narrative
Discussion
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