Subjective:
Dispatch info
Expert provided info
Bystander information
Pt complaint
Pt admits
Pt denies
Pt info
Objective:
Scene info:
Pt found:
X: Obvious life threats appreciated?
A: Airway status, self-protected?
B: Rate, breath sounds
C: Skin quality, capillary refill, pulse rate and quality, EKG findings
D: Mental status, neurological findings, commands, questions, phonation
E: Exposure/environmental concerns
F: BG
G: Pregnancy
Head to toe: relevant findings, abdomen, trauma:
Neurovascular function:
Specialty tests:
Vitals as above:
Assessment:
Chief Complaint
Differentials considered
Plan:
Chronological order of all events.
All times are estimates.
Quotes are from memory.