EMS Respiratory Distress Care Record

Incident Number: [Incident number]

Unit ID: [Unit identifier]

Service Level: [BLS / ALS / CCT]

Agency: [Agency name]

Crew: [Crew members with roles and identifiers]

Times

• Unit Notified: [Date/time (24-hr)]
• En Route: [Date/time (24-hr)]
• On Scene: [Date/time (24-hr)]
• Patient Contact: [Date/time (24-hr)]
• Depart Scene: [Date/time (24-hr)]
• Arrive Destination: [Date/time (24-hr)]
• Available: [Date/time (24-hr)]

Location/Scene

Address: [Street address, city]

Location Type: [Private residence / Skilled nursing facility / Public place / Workplace / Other]

Relevant Environmental Factors: [Smoke exposure / Irritant exposure / Allergen exposure / Poor ventilation / Recent exertion / None identified] (Include source, duration, and proximity if applicable.)

Reason for Encounter

• Dispatch Complaint: [Dispatch determinant or complaint]
• Chief Complaint: [Patient's own words in brief quote when possible] (If patient unable to provide, document reason and source of information.)
• Protocol Pathway: [Protocol tag or pathway if applicable]

Initial Assessment & Severity

• Airway: [Patent / Partially obstructed / Obstructed] (If abnormal, note secretions, edema, foreign material.)
• Breathing: [Adequate / Inadequate] (Support with rate, effort, chest rise.)
• Perfusion: [Adequate / Poor] (Support with pulse quality, skin perfusion.)

Severity Descriptors at Baseline:

• Ability to Speak: [Full sentences / Phrases / Words only / Unable]
• Position: [Tripod / Sitting upright / Supine intolerance / Other]
• Work of Breathing: [Accessory muscle use / Retractions / Nasal flaring / Paradoxical breathing / None observed]
• Skin Signs: [Cyanosis / Diaphoresis / Pallor / Mottling / Normal]
• Mental Status: [Alert and anxious / Fatigued or lethargic / Decreased responsiveness]

Working Impression: [Clinical concern based on initial presentation] (State suspected syndrome without assigning definitive diagnosis.)

History of Present Illness

[Narrative paragraph beginning with chief complaint, covering: onset and course (timing, sudden vs gradual, progressive vs episodic); associated symptoms with relevant positives and negatives (chest pain, fever, cough/sputum, orthopnea/PND, leg swelling, recent illness); triggers and context (exercise, allergens, smoke, medication nonadherence, dialysis noncompliance); home or bystander treatments prior to EMS arrival with response noted. Maintain chronological order.]

Past History, Medications, Allergies

• Pulmonary History: [Asthma / COPD, prior ICU/intubation, home oxygen use and flow, baseline SpO2 if known] (If unobtainable, document reason.)
• Cardiac/Renal History: [CHF, CAD, arrhythmia, CKD/ESRD, dialysis schedule] (Include factors relevant to pulmonary edema risk.)
• Medications: [Current medications with emphasis on inhalers, steroids, diuretics, nitrates]
• Allergies: [Allergies to bronchodilators, steroids, epinephrine, aspirin, nitrates] (Include reaction type.)
• History Source: [Patient / Family / Bystander / Facility staff / Records] (Note if limited or unobtainable and why.)

Physical Examination

• General Appearance: [Mild / Moderate / Severe distress], [speech ability], [posture/positioning], [fatigue level]
• Airway: [Patent / Secretions / Stridor / Upper airway noise / Edema]
• Breathing/Chest:
  • Auscultation: [Wheezes / Rhonchi / Crackles / Diminished / Absent] [Left / Right / Bilateral]
  • Air Entry: [Good / Reduced / Absent] [Left / Right / Bilateral]
  • Expiratory Phase: [Prolonged / Normal]
  • Chest Wall: [Symmetric / Asymmetric], retractions [Intercostal / Suprasternal / Subcostal / None], accessory muscle use [Present / Absent]
• Cardiovascular: [Rate/rhythm], peripheral edema [Present / Absent], JVD [Present / Absent / Not assessed], skin [Warm / Cool], [Dry / Diaphoretic]
• Pertinent Negatives: [No urticaria / No tongue or lip swelling / No audible stridor / No unilateral breath sound absence / No trauma signs] (Include only if specifically assessed to inform differential.)

Vital Signs & Monitoring

• Baseline Vitals: [Time], HR [value], BP [value], RR [value], Temp [value if obtained], Mental Status [AVPU or GCS]
• SpO2: [Value %] on [Room air / Nasal cannula at L/min / Simple mask at L/min / Nonrebreather at L/min / CPAP/BiPAP at settings] (SpO2 must include oxygen delivery condition. If unreliable, document reason and corrective actions.)
• Capnography: EtCO2 [value], RR [device value], Waveform [Normal rectangular / Shark-fin / Artifact] (If clinically relevant but not used, document reason.)
• ECG Monitoring: [Monitor applied / 12-lead obtained], [Rate/rhythm/findings] (Include if cardiac concern present.)

Interventions

(Document each intervention chronologically with time, indication, details, tolerance, response, complications, and reassessment plan.)

Oxygen Therapy

• Time: [Date/time (24-hr)]
• Indication: [Hypoxemia / Increased work of breathing / Suspected CO exposure] linked to findings
• Device & Settings: [Nasal cannula / Simple mask / Nonrebreather / Other] at [Flow L/min or FiO2 %]
• Patient Position: [Upright / Semi-Fowler / Fowler / Lateral]
• Target Saturation: [Target range %] (State rationale if restrictive targets used.)
• Response: SpO2 [before → after with device], work of breathing [change], speech ability [change]
• Tolerance: [Tolerated well / Anxiety / Claustrophobia / Other]

Nebulized Bronchodilators

• Time: [Date/time (24-hr)]
• Medication/Dose/Route: [Name], [dose], [nebulized via mask / mouthpiece / in-line with CPAP]
• Number of Treatments: [Count and intervals]
• Indication: [Wheezing / Bronchospasm / Increased WOB] with supporting findings
• Response: Lung sounds [change by side], WOB [change], RR [before → after], SpO2 [before → after with device], speech [change]
• Tolerance: [Tolerated / Tachycardia / Tremor / Anxiety]

CPAP/BiPAP

• Time: [Date/time (24-hr)]
• Indication: [Persistent hypoxemia / Respiratory distress with increased WOB / Suspected pulmonary edema] with specific findings
• Contraindication Screening: [Performed] (Document relevant factors: vomiting, facial trauma, decreased LOC.)
• Interface & Settings: [Mask type], [Pressure/PEEP], [FiO2 %]
• Coaching/Tolerance: [Coaching required / Not required], [tolerance level]
• Response Over Time: SpO2 [trend with settings], EtCO2/waveform [if used], WOB [change], speech [change], breath sounds [change by side]
• If Discontinued: [Reason and time]

Airway Escalation

• Time: [Date/time (24-hr)]
• Indication: [Airway protection / Failure of ventilation/oxygenation / Altered mental status]
• Adjuncts/Devices: [OPA / NPA / Supraglottic airway / ETT size and depth]
• Confirmation: [Waveform capnography / Bilateral chest rise / Auscultation / Tube marker depth]
• Ventilation Settings: [BVM / Ventilator settings], [FiO2 %], [PEEP if used]
• Complications: [None / Aspiration / Hypotension / Hypoxia] and management

Additional Medications

• Time: [Date/time (24-hr)]
• Medication: [Steroid / Epinephrine / Nitrate / Diuretic / Magnesium] with dose and route
• Indication: [Finding-to-therapy linkage]
• Response: [Objective changes]
• Adverse Effects: [None / Describe]

Reassessments

(Document after each intervention, at intervals during transport, and upon arrival. Repeat as needed.)

• Time: [Date/time (24-hr)]
• Respiratory Rate: [Value]
• SpO2: [Value %] on [Device and flow/FiO2]
• EtCO2 & Waveform: [Value and waveform descriptor] (If used.)
• Work of Breathing: [Accessory muscle use / Retractions / Nasal flaring / None]
• Breath Sounds: Left [findings], Right [findings]
• Mental Status: [AVPU/GCS]
• Response Classification: [Improved / Unchanged / Worsened] with brief objective justification

Transport & Destination

• Transport Priority: [Emergent / Non-emergent] with rationale based on objective findings or response
• Destination: [Facility name] (Reason for selection and any bypass rationale.)
• Patient Positioning: [Upright / Semi-Fowler / Lateral]
• Continuous Monitoring: [SpO2 / EtCO2 / ECG / BP intervals]

Communications

• Pre-Arrival Notification: [Type of alert] at [time] to [recipient/facility]
• Medical Control Contact: [Time], [clinician], [orders received]
• Interagency Coordination: [ALS intercept / Fire / Law enforcement] with times and roles (If applicable.)

Handoff & Disposition

• Condition at Transfer: [Stable / Guarded / Critical]
• Final Vitals: HR [value], BP [value], RR [value], SpO2 [value %] on [device/settings], EtCO2 [value if used], Mental Status [AVPU/GCS]
• Breath Sounds at Handoff: Left [findings], Right [findings]
• Treatment Summary: [Concise summary of key interventions and responses]
• Belongings/Equipment: [Items transferred including home respiratory equipment]

Documentation principles: Maintain chronological order with time stamps for all events, interventions, and reassessments. Use objective, observable findings; pair clinical impressions with supporting data. When clinically relevant assessments or interventions are not performed, document the reason (unable/contraindicated/unavailable/refused/already performed). Distinguish between not obtained, unknown, and not applicable. Do not auto-populate normal findings without documented assessment. SpO2 values require concurrent oxygen delivery conditions.