Clinical Charting for NRP Students

Room Number/Unit: 
[text name="incident" default=" "]
Patient Age: 
[text name="variable_1" default=""]
Patient Sex:[checkbox name="variable_1" value="Male| Female| Unknown"]
Initial Observations (Room/Patient):  
[textarea name="Variable_1" default=" "]
Reason for Admit/Visit:  
[text name="variable_1" size = 55 default="Trauma/Medical"]

Hx: 
Onset: [text name="O" size = 55 default=" "]
Provoking/Relieving Factors: [text name="P" size = 55 default=" "]
Quality/Described As: [text name="q" size = 55 default=" "]
Radiation: [text name="r" size = 55 default=" "]
Severity: [text name="s" size = 55 default=" "]
Acute/Chronic: [text name="t" size = 55 default=" "]
Additional Signs/Symptoms Reported: [textarea name="s" size = 55 default=" "]
Allergies: [text name="a" size = 55 default=" "]
Medications: [textarea name="m" size = 55 default=" "]
Past Med Hx: [text name="p" size = 55 default=" "]
Last Oral Intake: [text name="p" size = 55 default=" "]
Events Surrounding Condition: [textarea name="e" size = 55 default=" "]

Assessment: 
General/Overall Appearance: [textarea name="appearance" default="Pt weight, ethnicity, health habits, eating, mental health"]
Airway: [checkbox name="airway" value="open| maintained by patient| no concerns for compromise| not open| compromised| requires manual opening| requires airway adjunct| requires advanced airway"][text name="airway" size = 55 default=" "]
Breathing: [checkbox name="breathing" value="normal and regular rate. | fast| deep| slow| shallow| apneic"][text name="airway" size = 55 default=" "]
Circulation: [checkbox name="circulation" value="normal and without concerns| Regular and normal pulse rate| Tachycardic| Bradycardic| Weak pulse| massive hemorrhage| Diminished perfusion| Pulseless"][text name="airway" size = 55 default=" "]
Level of Consciousness: [checkbox name="loc" value="alert| oriented| Person| Place| Time| Event| disoriented| arousable by verbal stimuli| arousable by painful stimuli| unresponsive"][text name="consciousness" size = 55 default=" "]
SKIN: [checkbox name="skin" value="pink| warm| dry |pale |cool| clammy| diaphoretic| hot| flushed| cyanotic| lividity| jaundiced"][text name="skin" size = 55 default=" "]
HEENT: [checkbox name="head" value="normal and atraumatic. |no reported pain| pupils equally round and reactive"][text name="head" size = 55 default=" "]
Neck: [checkbox name="neck" value="normal and atraumatic| no JVD| no tracheal deviation| no reported pain"][text name="neck" size = 55 default=" "]
Chest: [checkbox name="chest" value="normal and atraumatic| breath sounds clear equal bilaterally| no reported pain"][text name="chest" size = 55 default=" "]
Back: [checkbox name="back" value="normal and atraumatic| no reported pain"][text name="back" size = 55 default=" "]
Abdomen: [checkbox name="abdomen" value="normal and atraumatic| no pain"][text name="abdomen" size = 55 default=" "]
Pelvis: [checkbox name="pelvis" value="normal and atraumatic| no reported pain"][text name="pelvis" size = 55 default=" ]
Extremities: [checkbox name="extremities" value="normal and atraumatic| equal grip strength x4| cap refill less than 2 seconds| skin pink warm dry| no reported pain"][text name="extremities" size = 55 default=" "]
Additional Assessment Findings: [textarea name="additassess" default=" "]
EKG: [checkbox name="ekg" value="12 lead EKG| 4 lead cardiac monitoring| normal sinus rhythm| sinus tachycardia| no ST Elevation or ectopy| no EKG performed"][text name="ekg" size = 55 default=" "]

Initial Vital Signs: 
[textarea name="vitals" default="BP _/_; HR _; SPO2 _; ETCO2 _; RR _; Pain _/10 "]

Second Vital Signs: 
[textarea name="vitals" default="BP _/_; HR _; SPO2 _; ETCO2 _; RR _; Pain _/10 "]

Third Vital Signs: 
[textarea name="vitals" default="BP _/_; HR _; SPO2 _; ETCO2 _; RR _; Pain _/10 "]

Impression: [text name="imp" size = 55 default=" "]

Rx Administered: 
[textarea name="variable_1" default="Meds"]

Treatment included: [checkbox name="treatment" value="primary and secondary ALS assessment| cardiac monitoring"] [textarea name="rxt" default=" "]

Skills Performed: 
[textarea name="variable_1" default="IV, Site, Size, Reason"]

Provider: [text name="prov" size = 45 default=" "]
Level of Care: [checkbox name="care" value="NRP. |EMT. |AEMT. |EMT-I"]