EMS Opioid Overdose/Naloxone Administration Note

Date/Time: [Date and time of documentation] (Use consistent format with timezone throughout, e.g., YYYY-MM-DD HH:mm z)

Unit/Agency: [Unit identifier and EMS agency]

Crew: [Crew member names and roles]

CAD/Run #: [Run number] ePCR #: [ePCR number]

Dispatch: [Time] En Route: [Time] On Scene: [Time] Patient Contact: [Time]

Depart Scene: [Time] At Destination: [Time] Transfer of Care: [Time]

Scene Location: [Address or descriptive location]

Destination Facility: [Facility name and department/unit if applicable]

Chief Concern

[Dispatch reason and EMS impression on arrival; pre-arrival naloxone administration if applicable] (1–2 sentences. Note who administered pre-EMS naloxone if known. Use source attribution: "Per bystander...", "Per law enforcement...")

Scene Assessment & Suspected Agents

• Initial scene findings: [Patient position/location; evidence of apnea/agonal respirations/cyanosis; emesis/aspiration risk; environmental exposures] (Use neutral, observable language.)
• Observed evidence: [Paraphernalia, medication containers, residue, alcohol containers, other items] (Describe without inference.)
• Reported substances: [Patient statement after reversal; bystander/LE/fire report] (Use direct quotes for key patient claims. Attribute all sources.)
• Co-ingestant concerns: [Alcohol / benzodiazepines / stimulants / pressed pills / unknown / none identified] (Include only if supported by report or observation.)
• Last known well / downtime: [Estimated interval with source and degree of certainty]

(If scene details unavailable, state reason briefly: unsafe scene, no historian, rapid extrication.)

Initial Assessment

• Airway: [Patency, protective reflexes, secretions/emesis, maneuvers required, adjuncts considered/placed]
• Breathing: [RR, effort, breath sounds, apnea/agonal respirations]
• Oxygenation: [SpO₂ with device/FiO₂; ETCO₂ if obtained; cyanosis present/absent]
• Circulation: [Pulse presence/quality, HR, BP, perfusion/skin signs]
• Neuro: [AVPU or GCS with subscores, pupil size/reactivity, seizure activity, ability to protect airway]

Immediate threat category: [Respiratory depression with pulse / respiratory arrest with pulse / cardiac arrest-pulseless / undifferentiated AMS with adequate respirations] (If naloxone given diagnostically for undifferentiated AMS, state rationale.)

History

(Include when obtainable. Label each item by source. If no historian available and patient remains obtunded, state this explicitly and omit the list below.)

• Events: [Circumstances leading to presentation, witnessed collapse if applicable]
• Medications/substances: [Prescribed opioids, MOUD (methadone/buprenorphine), recent dose changes, non-prescribed substances]
• Allergies: [Allergen and reaction type]
• Pertinent PMH: [COPD/OSA, liver disease, pregnancy, seizure disorder, other relevant conditions]
• Baseline function: [Usual mentation and respiratory status]
• Trauma history: [Fall, assault, head strike, or none reported with mechanism and timing]

Secondary Survey

• Respiratory: [Auscultation findings, work of breathing, accessory muscle use, chest rise symmetry]
• Neurologic: [Orientation, focal deficits, motor/sensation; injection sites if noted] (Use neutral terms such as "injection marks noted.")
• Trauma screen: [Head/neck/chest/abdomen/pelvis/extremities; pressure injuries if prolonged downtime] (Include pertinent negatives only if assessed.)
• Glucose: [Value and time] (Obtain when AMS not fully explained.)
• Temperature: [Value, route, time] (Include if obtained.)

Airway & Ventilation Interventions

(Document in time-stamped sequence. Ventilation and oxygenation should be addressed alongside or before naloxone per resuscitation best practices. If no airway interventions required after assessment, state this briefly and omit the log.)

• [Time]: [Intervention: positioning / suctioning / OPA-NPA placement / BVM ventilation with rate and adjuncts / oxygen therapy with device and flow / CPR-AED if pulseless with initial rhythm] → Response: [Change in SpO₂, ETCO₂, work of breathing, mental status]

(Repeat for each intervention as needed.)

Naloxone Administration

Indication: [Apnea / hypoventilation / AMS with suspected opioid exposure / diagnostic trial]

Intended endpoint: [Titrate to adequate spontaneous ventilation / return to baseline mentation]

Dose Log: (Repeat structure for each dose. Include reliably reported pre-EMS doses with source attribution and note as approximate.)

• Time: [Time] Dose/Formulation: [Amount and concentration] Route: [IN / IV / IM / IO / SC] [Site/device]
• Administered by: [EMS / bystander / law enforcement / fire]
• Response: [improved / unchanged / worse] with [RR, SpO₂, ETCO₂, GCS, airway protection]
• Complications: [Vomiting / agitation-withdrawal / aspiration concern / restraints required / none]

Post-naloxone monitoring: [Reassessment intervals and trends; need for repeat dosing; suspicion for long-acting opioid or high-potency exposure] (If naloxone not given, state rationale: adequate respirations, alternate diagnosis, refusal.)

Clinical Course

[Time-anchored narrative summarizing: initial severity, interventions provided, first measurable improvement, subsequent stability or recurrence, final status including airway patency, ventilation adequacy, mentation, and vital signs] (4–8 sentences. Focus on clinical turning points; avoid duplicating dose log details.)

Disposition

Transport

• Destination: [Facility name] Rationale: [Capabilities, proximity, patient preference]
• En route monitoring: [SpO₂/ETCO₂ trends, repeat assessments, repeat naloxone if given, aspiration precautions]
• Safety measures: [Agitation management, restraints if used with clinical justification, positioning]

Non-transport / Refusal

(High-risk scenario requiring detailed documentation. Include only if non-transport/refusal occurred.)

• Capacity assessment: [Orientation; ability to paraphrase risks/benefits/alternatives; absence of incapacitating intoxication]
• Recommendation given: [Transport/ED evaluation recommended and rationale]
• Risks explained: [Recurrent respiratory depression after naloxone wears off; other pertinent risks communicated]
• Alternatives offered: [Transport options, family involvement, medical control contact if required]
• Patient's decision: [Direct quote of refusal statement strongly preferred]
• Return precautions: [Instructions for symptom recurrence and when to call 911]
• Witness/support: [Names and relationships of persons present] Left with: [Responsible adult if applicable]
• If form unsigned: [Reason and witnesses]

Transfer of Care

Receiving clinician: [Name and role] Time: [Time]

Handoff summary:

• Initial status: [Respiratory status and key vitals on arrival]
• Airway/ventilation support: [Interventions and response]
• Naloxone: [Total doses, times, routes; response pattern; any recurrence]
• Concerns: [Complications, co-ingestant suspicion, trauma concerns with source attribution]
• POC results: [Glucose, ETCO₂ values if obtained]

(Meta-instructions: Distinguish sources throughout—attribute to patient, bystander, law enforcement, fire, or direct observation. Prioritize objective findings over interpretation. Document uncertain information as approximate with source. For missing information, state reason rather than leaving blank. Avoid asserting specific opioid, intent, or declaring resolution unless clearly supported. Omit inapplicable sections rather than including empty placeholders.)