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EMS Patient Care Report - 11/18/95
PINELLAS C0UNTY EMS PATIENT CARE REPORT Date: 11/18/95 Incident: 206964 Call Received: 1755 Patient: 01 of 01 Dispatch: 1755 Pat Depart: 1830 En Route: 1755 Unit Depart: 1830 Arrive Loc: 1755 Arrive Dest: 1838 Pat Contact: 1756 Available: 1901 Nature of Call: Behavioral Call Status: _X_ To Scene _X_ From Scene Call Level: ALS Exposure: No Assist: EMS Disposition: Transport Type of Transport: Ground Incident Location: 515 Belleview Bl Last Name: McPherson First Name: Lisa Street Address: 2324 Jonesboro Av City: Dallas State: TX Zip: 75228 Date of Birth: 2/10/59 Sex: Female Race: White Age: 36 Airway: Patent Breathing: Sounds Temp: WNL Color: WNL Moisture: WNL Pupils: _X_ WNL _X_ WNL Glasgow Coma Scale: Eyes: Spont Verbal: Confused Motor: Obeys Total: 14 Circulation: Radial Time: 1812 Pulse: 126 Resp Rate: 18 BP Systolic: 160 BP Diastolic: 102 PINELLAS COUNTY EMS SUPPLEMENTAL SHEET Patient Name, Last, First: McPherson, Lisa Skin w/n, * PMS y4, ABP S & NT, Pt stated she's having a difficult time & / t doing bad things in her mind & doing wrong things that she didn't know were wrong. One example "I took my eyes off the object" VP, 10, 20, EKG, GSC trans ALS -> MPH s incident pt states she needs to rest. REFUSAL OF CARE ALGORITHM [This is the back of the EMS Patient Care Report. It includes an ECG Strip marked:] 18:13 18 NOV 95 LEAD II XI 0_HR=127 RELEASE OF MEDICAL ASSISTANCE A Release of Medical Assistance form, signed by Lisa McPherson. It says:
Lisa only signed her name, checked the Patient box (rather than Guardian), and wrote her phone number, 559-9886. She did not fill in an address. There are notes written on the reverse side that have bled through; they are very hard to read, but appear to include the comments: "PT states she needs to talk ... people think she was crazy. Pt has agitated state ... Pt states she is Scientologist. ... Cont to ask me ... " This is probably the Refusal form mentioned in the police interview with paramedic Bonnie Portolano. continuation of the PINELLAS C0UNTY EMS PATIENT CARE REPORT There are no items marked in the following sections of the form:
There are no items checked under (medical) History. Current Meds: None Allerlgies: None Known Chief Complaint: "I need help, I need to talk to someone" Narrative: 36 y/o WF involved in minor MVA. No injuries pt signed refusal. As we were leaving pt came walking down the road naked. We guided pt in unit. Pt stated she needs to talk, that she didn't need a body to live, stated she's an O.T., stated she took her clothes off to make people think she was crazy. Pt has a fixed stare, speak in a programmed & formal manner. Pt stated she is a scientologist, is clear, +=, EKG ST, pupils WNC, O JVD, pt switches topics as she speaks unable to stay focused on one topic. Cont to ask me to repeat the question. R/O behavioral disorder Lead Crew Signature: Bonita Portolano Destination Address: MPH (Morton Plant Hospital) Hospital Selection: Nearest Facility Response Code: ALS Moved to Ambulance: Stretcher Transport Position: Head Elevated Oxygen Supplied: N Patient: 901 Oceola #205 Clwr FL 34616 Patient Phone: 559-9886 Patient SS #: 461-94-2009 Guarantor Name, Last, First: McPherson, Lisa Guarantor Address: SAA Worker's Comp: N Hospice: N Employer Company Name: AMC Publishing Employer Phone #: 446-1100 Employer Company Address: XXXX Lakeview 34616 |