Complete Note
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DISPATCHED TO:[textarea name="dispatch" default=" "]

RESPONSE: [checkbox name="RESPONSE" value="EMERGENT.|NONEMERGENT.|LIGHTS/SIRENS.|LIGHTS NO SIRENS.|NO LIGHTS NO SIRENS.|UPGRADED TO EMERGENT.|DOWNGRADED TO NONEMERGENT."][text name="RESPONSE" default=" "]

APPARATUS: [checkbox name="APPARATUS" value="MED 1.|MED 2.|MED 3.|MED 4.|MED 5.|ENGINE 10.|ENGINE 12.|FIRE 1."][text name="APPARATUS" default=" "]

UPON ARRIVAL:[textarea name="arrived" default=" "]

CHIEF COMPLAINT:[text name="CC" size = 55 default=" "]

SECONDARY COMPLAINT(s):[text name="CC" size = 55 default=" "]


HX OF PRESENT ILLNESS/INJURY:[textarea name="HX_OF_PRESENT_ILLNESS" default=" "]
PAST MEDICAL Hx:[textarea name="pmhx" default=" "]

ALLERGIES:[checkbox name="allergies_check" value="NKDA.|PENICILLIN.|SULFA.|LATEX."][text name="allergies" default=" "]

Initial ABC's:
-Airway: [checkbox name="airway" value="airway open.|airway patent.|no airway obstructions.|Normal.|airway positioned to open.|airway not patent.|obstructions to airway.|requires airway adjunct.|requires advanced airway.|requires artificial ventilation."][text name="airway" default=" "]

-Breathing: [checkbox name="breathing" value="breathing spontaneously.|breathing regular.|adequate respirations.|appropriate tidal volume.|no apparent life threats to breathing.|Normal.|not breathing spontaneously.|irregular respirations.|inadequate respirations.|inadequate tidal volume.|apparent life threats to breathing."][text name="breathing" default=" "]

-Circulation: [checkbox name="circulation" value="no obvious bleeding.|pulses intact.|skin color appropriate.|cap refill <2 seconds.|no life treats to circulation status.|normal.|hemorrhage present.|hemorrhage controlled.|tq applied.|pulses not intact.|skin color not appropriate.|cap refill >2 seconds.|life threatening concerns with circulation."][text name="ros_constitutional" default=" "]


Review of symptoms:

-Constitutional: [checkbox name="ros_constitutional_check" value="no fever.|no chills.|no weakness.|no fatigue.|no malaise.|fever.|chills.|weakness.|malaise."][text name="ros_constitutional" default=" "]
-HEENT: [checkbox name="ros_heent_check" value="no vision changes.|No ear pain.|no nasal congestion.|no sore throat.|no cough."][text name="ros_heent" default=" "]
-Cardiovascular: [checkbox name="ros_cardio_check" value="No chest pain|no palpitations.|no swelling of extremities.|Normal.|chest pain.|palpitations.|swelling of extremities."][text name="ros_cardio" default=" "]
-Respiratory:[checkbox name="ros_resp_check" value="No shortness of breath.|no hemoptysis.|no dyspnea.|Normal.|shortness of breath.|hemoptysis.|dyspnea."][text name="ros_resp" default=" "]
-GI: [checkbox name="ros_gi_check" value="No change in appetite.|no abdominal pain.|no hematemesis.|Normal.|change in appetite.|no N/V/D.|Abdominal pain.|hematemesis.|Nausea.|Vomiting.|Diarrhea."][text name="ros_gi" default=" "]
-GU: [checkbox name="ros_gu_check" value="no urinary frequency.|no urinary urgency.|no dysuria.|no hematuria.|no leakage of urine.|Normal.|urinary frequency.|urinary urgency.|dysuria.|hematuria.|leakage of urine."][text name="ros_gu" default=" "]
-MSK: [checkbox name="ros_msk_check" value="no back pain.|no joint pain.|no muscle aches.|no generalized muscle pain.|no neck pain.|Normal.|back pain.|joint pain.|muscle aches.|generalized muscle pain.|neck pain."][text name="ros_msk" default=" "]
-Skin: [checkbox name="ros_skin_check" value="no rash.|no bruising.|no lesions.|no itching.|Normal.|rash.|bruising.|lesions.|itching."][text name="ros_skin" default=" "]
-Neuro: [checkbox name="ros_neuro_check" value="no headache.|no dizziness.|no syncope.|no loss of consciousness.|Normal.|headache.|dizziness.|syncope.|loss of consciousness."][text name="ros_neuro" default=" "]
-Psych: [checkbox name="ros_psych_check" value="denies Suicide ideation/homicide ideation.|No hallucination.|No depression.|no anxiety.|Normal.|Suicide ideation\homicide ideation.|hallucinations.|depressed.|anxious."][text name="ros_psych" default=" "]
-Endocrine: [checkbox name="ros_endo_check" value="no heat/cold intolerance.|no excessive thirst.|no polyuria.|Normal.|heat intolerance.|cold intolerance.|excessive thirst.|polyuria"][text name="ros_endo" default=" "]
-Hematologic: [checkbox name="ros_heme_check" value="no excessive bruising.|no excessive bleeding.|Normal.|excessive bruising.|excessive bleeding."][text name="ros_heme" default=" "]
PHYSICAL EXAM
-Blood Pressure:[text name="pe_bp" default=" "]
-Pulse:[text name="pe_pulse" default=" "]
-SPO2:[text name="pe_spo2" default=" "]
-BGL:[text name="pe_bgl" default=" "]
-General: [checkbox name="pe_general_check" value="Well developed/well nourished.|Well appearing.|in no acute distress.|malnourished.|in acute distress.|obese."][text name="pe_general" default=" "]
-HEENT: [checkbox name="pe_heent_check" value="normocephalic.|atraumatic.|PERRLA.|white sclera.|conjunctiva pink/red|ears patent.|no bleeding.|bleeding.|positive HALO test.|negative HALO test.|dry mucous membranes.|extra salivation. |normal mucous.|normal pharynx.|no trauma to mouth.|Normal.|trauma to face.|trauma to mouth."][text name="pe_heent" default=" "]
-Cardiovascular: [checkbox name="pe_cardio_check" value="Regular rate and rhythm.|no ST elevation.|no jugular vein distention.|no edema.|peripheral pulses intact.|no cyanosis.|capillary refill < 2 seconds.|Normal.|irregular rate.|irregular rhythm.|ST elevation present.|JVD present.|edema present.|no peripheral pulses.|cyanosis present.|capillary refill greater than 2 seconds.|bleeding.|trauma.|atraumatic."][text name="pe_cardio" default=" "]
-Respiratory: [checkbox name="pe_resp_check" value="Clear to Auscultation bilaterally.|no rales, rhonchi, wheezes.|no retractions.|no accessory muscles being used.|no stridor.|Normal.|wheezing.|upper respiratory congestion.|Diminished breath sounds."][text name="pe_resp" default=" "]
-GI:[checkbox name="pe_gi_check" value="atraumatic.|BS present in all 4 quadrants.|abdomen soft/non-tender to palpation.|non-distended.|No rigidity.|no guarding.|no masses.|Normal.|Trauma present.|Tender abdomen.|Rigid abdomen.|distended abdomen.|Guarding present.|masses present."][text name="pe_gi" default=" "]
-MSK: [checkbox name="pe_msk_check" value="normal Range of movement.|no pain on palpation.|strength 5/5 in all extremities.|Normal.|abnormal range of motion.|pain on palpation.|strength not present in all extremities."][text name="pe_msk" default=" "]
-Skin: [checkbox name="pe_skin_check" value="no rash.|no lesion.|no discoloration.|pink.|warm.|dry.|pale.|cool.|cyanotic.|flushed.|clammy.|hot.|Normal."][text name="pe_skin" default=" "]
-Neuro: [checkbox name="pe_neuro_check" value="Grossly oriented X 4.|gait normal.|sensation intact.|normal reflexes.|smile normal.|speech not slurred.|Normal.|Neuro not grossly intact.|gait abnormal.|sensation absent.|no reflexes.|smile not symmetrical.|slurred speech."][text name="pe_neuro" default=" "]
-Psych: [checkbox name="pe_psych_check" value="Pleasant, calm and cooperative.|Judgement and insight intact.|makes a plan.|understands treatment.|thought process normal.|normal affect.|At baseline.|unpleasant.|not calm.| not cooperative.|does not make plan.|does not understand treatment."][text name="pe_psych" default=" "]
-Hematologic: [checkbox name="pe_heme_check" value="no tenderness or masses palpated.|no bruises.|no bleeding.|Normal.|tenderness/masses.|bruising.|bleeding."][text name="pe_heme" default=" "]

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

TRANSPORT: [checkbox name="pe_trans_check" value="Secured to stretcher.|3 straps.|loaded for transport.|Emergency.|Non Emergency.|Emergency Downgraded to Non Emergency.|Non Emergency Upgraded to Emergency.|refusal.|AMA.|treat and release.|no transport.|lift assist only.|transported to SRM ER."][text name="pe_trans" default=" "]

REPORT: [checkbox name="pe_rep_check" value="Verbal report to nurse.|belongings left with nurse.|improvement in patient condition.|decline in patient condition.|no change in patient condition."][text name="pe_rep" default=" "]

Nurse/Physician:[text name="Nurse" size = 55 default=" "]

Signatures: [checkbox name="pe_rep_check" value="obtained from patient|obtained from guardian/POA|not obtained from patient|unable to sign|no representative available.|Nurse signed as witness."][text name="pe_rep" default=" "]

Provider writing report:[text name="RW" default=" "]
DISPATCHED TO:

RESPONSE:

APPARATUS:

UPON ARRIVAL:

CHIEF COMPLAINT:

SECONDARY COMPLAINT(s):


HX OF PRESENT ILLNESS/INJURY:
PAST MEDICAL Hx:

ALLERGIES:

Initial ABC's:
-Airway:

-Breathing:

-Circulation:


Review of symptoms:

-Constitutional:
-HEENT:
-Cardiovascular:
-Respiratory:
-GI:
-GU:
-MSK:
-Skin:
-Neuro:
-Psych:
-Endocrine:
-Hematologic:
PHYSICAL EXAM
-Blood Pressure:
-Pulse:
-SPO2:
-BGL:
-General:
-HEENT:
-Cardiovascular:
-Respiratory:
-GI:
-MSK:
-Skin:
-Neuro:
-Psych:
-Hematologic:

TREATMENT:

TRANSPORT:

REPORT:

Nurse/Physician:

Signatures:

Provider writing report:
Result - Copy and paste this output: