Be matter-of-fact. Be detailed. Record your surroundings. No subjective opinions. Use direct quotes.
And look it up or ask someone if you don’t know how to spell something. How unbelievably embarrassing when your mistake is projected onto a 8-foot screen in court.
This was a 25-year-old male who was found on the couch of a rather tidy residence with his head up his ass. He otherwise appeared to be in no apparent distress, had a strong odor resembling ETOH on his breath, and c/o that his “pussy hurt.”
He was polite and cooperative, but was a poor historian and did not provide much useful detail regarding his complaint despite crew’s multiple attempts to elicit such information. He denied any vaginal trauma/bleeding/spotting/discharge or dysuria. He denied any other pain/complaint or history of similar events.
He admitted to ingesting ETOH and using “a lot of meth” over the past 24 hours.
No obvious abnormalities noted in his genital area. Physical exam otherwise unremarkable.
Pt was instructed, sternly, to pull his head out of his ass and “quit being a little bitch.” He was then instructed to walk to the ambulance, which he did with a steady gait and no apparent difficulty.
Pt was transported without incident, and he rested quietly and comfortably on the gurney.
Pt care was transferred to ED staff without incident.
Sometimes I get writer’s block.