C (Complaint)
Discharge to Rehab SP treatment for CVA

H (History)
RN Reports PT: Was treated for Left CVA; Has confusion and weakness in the right side; Is A&Ox2; Is being discharged to rehab; PT requires BLS transport due to Weakness and confusion 2nd to CVA and requires full body lift for transfers. PMH, Meds, Allergies as noted.

A (Assessment)
78 YO Male PT found lying semi-fowlers in bed, CAOx2, ABC & HEENT unremarkable, Skin PWD, -NVD. PT presents with weakness and is not self-ambulatory. PT has baseline confusion. PT denies any non-baseline pain, nausea, headache, or difficulty breathing

Rx. (Treatment)
Vitals as noted.

T (Transport)
Bed to stretcher via full body sheet lift, adjusted, blanketed, secured, transported at TRF height to and secured in A06 all by EMTx2 and without incident. PT transported to Shady Acres without incident. OA, PT transported on stretcher at TRF height inside, to assigned room and bed, transferred via full body sheet lift, adjusted and secured appropriately all by EMTx2 and without incident. PT care and paperwork transferred to RN. A06 EMS no longer required by PT or RN and was cleraed without incident.