Section 1. Patient Details
Name: [insert patient name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Date of Birth: [insert patient date of birth] (only include date of birth if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Age: [insert patient age] (only include age if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Gender: [insert patient gender] (only include gender if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Chief complaint: [insert primary issue or complaint reported by or observed in the patient] (write as a brief phrase or sentence; only include if a chief complaint has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Section 2. Dispatch Information
Dispatch time: [insert time of dispatch] (only include dispatch time if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Incident location: [insert location of incident] (only include location if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Dispatch or vehicle number: [insert unit or vehicle ID number] (only include if number has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Emergency service officer name: [insert officer name] (only include if name has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Initial report: [insert details of initial report as received via dispatch] (write in sentence format; only include if initial report has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Section 3. Arrival
Emergency medical dispatch performed: [insert status of pre-arrival or on-arrival interventions] (state whether performed and by whom; only include if emergency dispatch information has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
If yes, elaborate on medical dispatch details performed: [insert description of what actions were taken prior to arrival or by bystanders] (write in brief sentences; only include if medical dispatch actions have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Chief complaint (reported by dispatch): [insert chief complaint as received from dispatch] (write as a brief phrase or sentence; only include if dispatch-reported complaint has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Initial assessment: [insert summary of initial assessment conducted upon arrival] (write in sentence format; only include if initial assessment has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Section 4. Health Condition
Previous medical history: [insert patient medical history] (write in short form using phrases or full sentence; only include if previous medical history has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medications: [insert list of current medications] (list or describe medications in-line; only include if medications have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Allergies (if known): [insert known allergies] (only include if allergies have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Patient chief complaint: [insert primary issue or reason for EMS attendance] (write in sentence format; only include if patient complaint has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Additional notes: [insert any further relevant health notes observed or reported] (write in brief paragraph format; only include if additional notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Section 5. Vital Statistics
Level of Consciousness (L.O.C): [insert patient’s LOC status across Alert, Voice, Pain, Unresponsive categories] (write responses inline; only include if LOC data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Speech: [insert status across Coherent, Incoherent, Slurred, Silent] (write responses inline; only include if speech status has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Skin: [insert condition of skin: Normal, Damp, Hot, Cold] (write responses inline; only include if skin condition has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Colour: [insert colour observations: Normal, Cyanotic, Flushed, Pale] (write responses inline; only include if colour observation has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Respiration: [insert status of respiration] (write response inline with description; only include if respiratory data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Pulse (bpm): [insert heart rate status] (write response inline with description; only include if pulse data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Blood Pressure: [insert status or measurement] (write in line format; only include if blood pressure data has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Additional notes/checks: [insert any additional observations relevant to vital signs] (write in sentence format; only include if any further vital notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Section 6. Physical Assessment
Injury Present: [insert Yes or No based on exam] (only include if presence or absence of injury has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Section 6a. Injury Details
Cause of injury: [insert cause if applicable] (write in phrase format; only include if injury cause has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Injury Type: [insert injury type classification] (write as Burn, Blunt, Penetration, Other or Unknown; only include if injury type has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Additional notes: [insert any other injury-related notes] (write in full sentence format; only include if additional injury notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Section 6b. Substance Indicators
Indicators: [insert substance-related indicators observed] (describe observed indicators such as smell of alcohol, slurred speech, etc.; only include if substance use indicators have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Additional notes (i.e., substance details): [insert additional substance-related notes] (write in sentence format; only include if substance-related notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Section 7. Additional Observations
Additional notes and procedures: [insert summary of procedures, notable observations, or medical decisions taken during or after the call] (write in paragraph format; only include if procedures or additional notes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Transport changes: [insert any changes in transport plan or method] (write in sentence format; only include if transport changes have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Signature: [insert provider signature if required] (only include if signature is required and has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Officer name: [insert officer full name] (only include if officer name has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Date (yyyy/mm/dd): [insert date of documentation] (only include if date has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)