AGE:  18 YEARS
REASON WHY YOU WERE DISPATCHED:head injury
COMPLAINT: left head/ facial injury.
SUBJECTIVE:pt was jumped by 3 people and was hit in the left side of the face and kicked in the stomach. pt is 1 month pregnant.
OBJECTIVE: pt had left side facial swelling to the left side of her face.
TREATMENT:took vitals and did and rapid trauma assessment. no burns, bleeding, or broken bones though out. no rigidity or distention in the stomach area. breath sounds clear bilaterally. transported to grady
CHANGES:

SELF REPORT SKILLS

 Directions: Check the box for all the skills you performed for this patient then press the 'Input Skill' button.  Click the delete button to remove extraneous skills.

DeleteObtain A Patient History from an Alert and Oriented Patient3/26/2017 8:50:29 PM 
DeleteComprehensive Normal Adult Physical Assessment Techniques3/26/2017 8:49:30 PM 
DeleteGlucometer3/26/2017 8:49:42 PM 

 

SELF REPORT TAGS

Directions: Check the box for all patient conditions, ages, and procedures (yes, some of the procedures would also be recorded above) that you peformed for this patient then press the 'Input Tag' button.  Click the delete button to remove extraneous skills.

 

 
  Mission Complete, Ready To Do Another PCR or Quit



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