CSI Narrative DCHART

D-DISPATCH
[textarea name="variable_1" default="CSI AUTO BILLING HEADER"]

CSI AVIATION DISPATCHED [select name="variable_1" value="ABQ flight crew|MAF flight crew|GRK flight crew|STU flight crew"] for a/an [select name="variable_1" value="Interfacility Transfer|Case Management Transport|Scene Call"] from [text name="variable_1" default="Sending Facility"] Hospital to [text name="variable_1" default="Receving Facility"] Hospital.  The Originating airport is [text name="variable_1" default="Airport Code"] and the arrival airport is [text name="variable_1" default="Airport code"].

H-HISTORY
This is a [text name="variable_1" default="age"] [select name="variable_1" value="MALE|FEMALE"] presented to [text name="variable_1" default="Sending Facility"] ED via [select name="variable_1" value="POV|EMS|PD/SO"] complaining of [text name="variable_1" default="Chief Complaint"] for the past [text name="variable_1" default="#"] [select name="variable_1" value="HOURS|DAYS|WEEKS|MONTHS"].  
The patient is being referred to a multi-service facility specializing in complex medical/surgical/psychiatric conditions with additional treatment methods for [text name="variable_1" default="diagnosis"] should the patient continue to deteriorate - referred to [select name="variable_1" value="|Neurology|Cardiology|Pulmonology|GI|Urology|Orthopedics|OB-GYN|Pediatric|Neonatal|Dialysis|Trauma|Other"] [text name="variable_1" default="Other/Specify"] for further evaluation adn treatment.  Patient is in need of a/an [select name="variable_1" value="ICU|Telemetry|Med Surg"] bed not available at the Sending facility.

Past Medical/Surgical/Psychiatric History of Patient:
[checkbox name="variable_1" value="NONE|COPD|CHF|HTN|Chronic Renal Failure/CKD|ESRD on HD|Diabetes Mellitus|Cardiac Arrhythmias
|other"][text name="variable_1" default="Other/Specify"]

Current Home Medications:
[textarea name="variable_1" default="sample text"]

A-ASSESSMENT
Upon arrival to [text name="variable_1" default="Sending Facility"], CSI Med Crew received report from [text name="variable_1" default="Name"],[select name="variable_1" value="RN/LVN|Medic|PA/NP|MD/DO"] and the patient was found in Room [text name="variable_1" default="#"].

Neuro: Patient is found to be alert and orient to: [checkbox name="variable_1" value="Person|Place|Time|Event"]
GCS [text name="variable_1" default="Sum"]: 
Best Eye Response: [select name="variable_1" value="4-Spontaneously|3-To Verbal Command|2-To Pain|1-No Eye Opening|NT-Not Testable"],
Best Verbal Response: [select name="variable_1" value="5-Oriented|4-Confused|3-Inappropriate Words|2-Incomprehensible Sounds|1-No Verbal Response|NT-Not Testable/Intubated"],
Best Motor Response: [select name="variable_1" value="6-Obeys Commands|5-Localizes Pain|4-Withdrawal From Pain|3-Flexion to Pain|2-Extension to Pain|1-No Motor Response|NT-Not Testable"]


Assessment:
GENERAL: [textarea name="appearance" default=" Interacting with EMS appropriately; well appearing; not acutely distressed. "]
CNS: [textarea name="CNS" default=" Speech is not slurred; CMS grossly intact in all 4 extremities; gait is steady. "]
PSYCH: [textarea name="psych" default=" No reported recent or active suicidality or homicidal ideations. No reported recent or active visual/auditory disturbances. "]
CARDIOVASCULAR: [textarea name="cardiovascular" default=" No immediate concerns. Equal radial pulses bilaterally. "]
PULMONARY: [textarea name="PULM" default=" No initial immediate concerns. Normal and adequate tidal volume and respiratory drive. "]
GI/GU: [textarea name="GIGU" default=" No nausea or vomiting. No changes in bowel reported. No changes in urine reported. "]

Physical Exam:
HEAD: [textarea name="head" default=" No noted pain or trauma. Pupils equally round/reactive at 4mm in size. No facial droop. "]
NECK: [textarea name="NECK" default=" No noted pain or trauma. No JVD. No midline pain. "]
CHEST: [textarea name="chest" default=" No noted pain or trauma. Equal rise and fall. Breath sounds CTA bilaterally. "]
BACK: [textarea name="back" default=" No noted pain or trauma. "]
ABDOMEN: [textarea name="abd" default=" No noted pain or trauma. Soft, flat, non-tender. "]
PELVIS: [textarea name="pelvis" default=" No noted pain or trauma. Stable. "]
EXTREMITIES: [textarea name="extremities" default=" No noted pain or trauma. No clubbing, cyanosis or edema. "]
SKIN: [textarea name="skin" default=" Normal tone, warm, dry. "]
VITALS: [textarea name="vitals" default=" "]
EKG: [textarea name="ekg" default=" "]

TREATMENT: 
[textarea name="treatment" default=" "]

TRANSPORT: 
[textarea name="TPU" default=" Transport non-emergent to HOSPITAL with pre-arrival notification made enroute. During transport patient remains stable."]

HOSPITAL ARRIVAL:
[textarea name="hosp" default=" Upon arrival at ED handoff given to nurse and provider at bedside. Nurse signs PCR. Patient signs PCR. "]

No further care.
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[checkbox name="Student" value="*Some assessments and procedures were performed by paramedic student who was under my direct supervision as the attending paramedic, and consistent with student's scope of practice.*"]
[checkbox name="Disclaimer" value="*Please note that this dictation was completed with computer voice recognition software. Oftentimes unanticipated grammatical, syntax, homophones, and other interpretive errors are inadvertently transcribed by the computer software. Please disregard these errors. Please excuse any errors that have escaped final proofreading.*"]