D = Dispatch
The dispatch was received at 14:30 for a 45-year-old male experiencing chest pain at a local gym. The responding unit, Medic 5, was dispatched with a priority 1 response. The location of the call was 123 Fitness Lane, and the nature of the call was a suspected cardiac event.
A = Arrival
Upon arrival at 14:40, the scene was safe with no visible hazards. The patient was found seated on a bench, appearing diaphoretic and clutching his chest. He was conscious but in distress, requiring assistance to stand.
C = Chief Complaint
The patient complained of severe chest pain radiating to his left arm, accompanied by shortness of breath and nausea.
H = History
The patient reported a history of hypertension and hyperlipidemia. He is currently on Lisinopril and Atorvastatin. No known drug allergies. He mentioned a similar episode of chest pain two years ago, which resolved without intervention.
A = Assessment
Primary assessment revealed the patient was alert and oriented. Vital signs: BP 160/95, HR 110, RR 24, SpO2 92% on room air. ECG showed ST elevation in leads II, III, and aVF. Lung sounds were clear bilaterally.
R = Treatment on Scene
Oxygen was administered at 4 L/min via nasal cannula. Aspirin 325 mg was given orally, and Nitroglycerin 0.4 mg sublingually, with partial relief of chest pain. IV access was established, and 0.9% saline was initiated.
T = Transport
The patient was transported to City Hospital with a priority 1 status. En route, the patient received continuous cardiac monitoring and a second dose of Nitroglycerin. Upon arrival, care was handed over to the emergency department staff, with a full report given to Dr. Smith.
E = Exceptions
There were no complications or deviations from protocol during the response and transport.
D = Dispatch
[insert a description of the dispatch details including the responding unit, other units involved, response mode, location of call, and nature of the call] (write as a paragraph in full sentences; include unit identification, response priority, address or type of location, and the type of call or complaint received via dispatch; only include if the information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
A = Arrival
[insert a description of the scene and patient status on arrival] (write as a paragraph in full sentences; describe the environment or hazards, where the patient was found, whether the patient was ambulatory or required assistance, and initial presentation upon EMS arrival; only include if the information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
C = Chief Complaint
[insert the patient’s or caregiver’s stated complaint or observed issue] (write in sentence or paragraph format depending on detail; summarise what was communicated as the main concern or symptom; if the patient could not communicate, describe how the primary complaint was inferred through diagnostic observation; only include if the information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
H = History
[insert the patient’s history of present illness and relevant past medical history] (write as a paragraph using full sentences; include reported symptoms using standard mnemonics if applicable, relevant past medical conditions, medication use, allergies, prior episodes, and details gathered from the patient or third parties regarding the current and previous events; only include if the information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
A = Assessment
[insert a summary of the primary and secondary assessments, vital signs, diagnostic findings, and relevant negatives] (write as a paragraph in full sentences; describe findings from the head-to-toe physical exam, neurological status, respiratory or cardiovascular signs, results from tools such as pulse oximetry, ECG, or glucometer, and any pertinent negatives; only include if the information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
R = Treatment on Scene
[insert a description of all interventions provided on scene, including time, provider, medication, and patient response] (write in paragraph format; include each treatment performed, who performed it, when it was administered, and how the patient responded; describe medications by dose, time, and route; only include if the information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
T = Transport
[insert a narrative of care during transport including mode of transport, interventions continued or initiated, patient condition changes, and handoff details] (write in paragraph format using full sentences; include transport priority, destination, any new or ongoing treatments, whether the patient's condition changed, who received handover at destination, and where the patient was transferred; only include if the information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
E = Exceptions
[insert a record of any complications, refusals, delays, deviations from protocol, or issues with transport or scene] (write in paragraph format using full sentences; include documentation of patient refusal, incomplete treatments, safety risks, or logistical problems; only include if the information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
