Toronto Paramedic Services and EMS Committee

PATIENT REPORT

BY TORONTO FIRE FIGHTER BRIAN KING, STATION 421-A, ASSISTED BY MICHAEL YOUNG FROM TORONTO PARAMEDIC SERVICES AND EMS COMMITTEE

This is Mary, she is 78 years old.

Mary called 911 today for troublebreathing, which has been ongoing for 4 hours. Mary has a history of COPD and lung cancer. She has taken her puffer. It didn’t help. Her O2 sat was 85% on room air prior to oxygen administration.

• Follow your SOGs, but keep it simple! Paramedics do not require a detailed patient report. Brief, to-thepoint, objective, and factual information is all that the paramedics require. • What is pertinent to paramedics? o Patient name and age o The reason for calling 911 and how long has this been going on o Medical history that is related to the patient complaint o Treatment that the patient/family/ bystanders may have provided o Any procedure or treatment that were performed by firefighters

Additional helpful tips and information to provide paramedics…

• Did firefighters move the patient? • Is CPR being done? Who started CPR first (firefighters/ family/bystanders)? • Have firefighters done anything with items on scene? Cut the rope? Moved bloody sheets? • If information was provided to firefighters that was not directly from the patient, who was it from?

*** Just as the hospital always reassesses patients that are brought in by paramedics, paramedics will always reassess patients that have been assessed by firefighters. ***

A Patient Report Structuring Tool:

You may be familiar with the “PC-SAMPLE method” of collecting patient information. This stands for:

If this is how you like to gather patient history, consider using this same format as the basis for your patient report. Focus it on pertinent information and it can be concise and repeatable. Over time, it stopped feeling like I was pulling patient information and call details out of thin air. It also stopped feeling like I was reinventing the wheel (regarding patient reports) on the spot, and for each medical call. Here is an example of what we hope may be a minor difference, but helpful structure and memory trick in the field.

P – Patient Information (name, age, etc) C – Chief Complaint S – Signs and Symptoms A – Allergies M – Medications P – Past Medical History L – Last Oral Intake E – Events Prior/Preceding

The things that are always appreciated by paramedics…

• Once care has been transferred to the paramedics, firefighters can stop further assessing and/ or questioning the patient (unless asked to by paramedics) and assist with patient care and extrication as requested • Ensure there is sufficient room in front of the address for ambulance parking and stretcher loading/unloading • Providing the patient’s health card and medications (bag/list)

Original Report Report in PC-SAMPLE structure

This is Mary, she is 78 years old.

Mary called 911 today for trouble breathing, which has been ongoing for 4 hours. Mary has a history of COPD and lung cancer. She has taken her puffer. It didn’t help. Her O2 sat was 85% on room air prior to oxygen administration. P – This is Mary, 78 C – Trouble Breathing, for 4 hours S – 02 sat 85% room air A – N/A M – Used puffer with no relief (give TPS the meds) P – History of COPD and lung cancer L – N/A E – Sitting at home

Don’t feel the need to use full sentences. One way to shorten your report can be to make it less conversational and more to the point (like a bullet point format) seen in the PC-SAMPLE method.

For TFS info on patient reporting refer to:

FCC-21-009-Attach-Patient-Care-Report g-emsr-emergency-medical-services-responses and report (section 3)