When asked, an alert and oriented 44-year-old male tells you that he called 911 because 'my chest is hurting.' The man is also sweating and feels as if he is going to vomit. He has a history of high blood pressure and states that this pain 'feels just like my heart attack two years ago.' His pulse is 88 beats per minute, respirations are 18 breaths per minute, and blood pressure is 156/92 mmHg. On room air, he has an oxygen saturation level of 95 percent. Based on this information, how would you document his chief complaint on the patient care report?

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Emergency Medical Services (EMS) documentation is important for patient care and legal matters. Documentation can include the patient's demographics, vital signs, assessment, and interventions performed. The documentation serves as a data repository that can be used to create bills, facilitate communication, and guide quality initiatives.


When asked, an alert and oriented 44-year-old male tells you that he called 911 because 'my chest is hurting.' The man is also sweating and feels as if he is going to vomit. He has a history of high blood pressure and states that this pain 'feels just like my heart attack two years ago.' His pulse is 88 beats per minute, respirations are 18 breaths per minute, and blood pressure is 156/92 mmHg. On room air, he has an oxygen saturation level of 95 percent. Based on this information, how would you document his chief complaint on the patient care report?






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