NW STUDENT PATIENT CARE REPORT
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DO NOT include any HIPAA protected information. No patient names, DOB, SS#, address', phone numbers, etc.
Clinical reports must be submitted no later than 72 hours after your shift. Reports will not be accepted after 72 hours.
Student Name
*
First Name
Last Name
Student's Personal Email
*
Confirmation Email
Do not use your school issued email
EMT Program
*
Please Select
NWCH Adult class
Tomball Memorial
Tomball High School
Klein Cain
Klein High School
Spring ISD
WIllis ISD
Date of Clinical
*
-
Month
-
Day
Year
Date
Clinical Location
*
Please Select
HCA Tomball
St. Luke's Vintage
NWCH
HCEC
Waller County
Harris County ESD #11
Atascocita Fire Dept.
MCHD
Unit number
*
Preceptors Name
*
First Name
Last Name
Patient Age
*
Gender
*
Male
Female
Chief Complaint
*
Primary Diagnosis
*
What do YOU think is wrong with them?
Secondary Diagnosis
*
Cannot be the same as Primary Diagnosis
Tertiary Diagnosis
Cannot be the same as Primary or Secondary Diagnosis
Allergies
*
Medical History
*
Medications
*
Vital Signs: Minimum 2 sets of VS
*
Select Narrative Type
*
DRAATT
SOAP
CHART
Hospital PCR
DRAATT
*
DISPATCH: RESPONSE: ARRIVAL: ASSESSMENT: TREATMENT: TRANSPORT:
SOAP
*
SUBJECTIVE: OBJECTIVE: ASSESSMENT (Differential Diagnosis): PERFORMED:
CHART
*
CHEIF COMPLAINT: HISTORY: ASSESSMENT: RX (TREATMENT): TRANSPORT:
Hospital PCR
*
COMPLAINT (why did they come to the ER?): EXAM/INTERVIEW (physical exam, Hx taking): TREATMENTS (List any treatments the patient received while in the emergency room): DISPOSITION (What happened to the patient, if you know?).
Interventions
*
Disposition
*
Treated & Transported
Refusal / No Transport
Death on Scene
Transported By Other Unit (air or ground)
You cannot submit this form unless you identify two DIFFERENT differential diagnosis.
By signing below you attest that the information you are submitting is correct and your own work:
*
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