VCEMS Narrative

C/C:[text name="O" size = 55 default=" "]
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: [text name="m" size = 55 default=" "]
Pertinent Past Med Hx: [text name="p" size = 55 default=" "]
Events Surrounding Condition: [textarea name="e" size = 55 default=" "]
Other Hx Info: [textarea name="otherhx" default=" "]
- Behavior: [checkbox name="behavior" value="tracking|appropriate|calm|anxious|excited/delirious|violent"]
- Skin:[checkbox name="skin" value="pink|warm|dry|pale|cool|clammy|diaphoretic|hot|flushed|cyanotic|lividity|jaundiced"]
- Work of breathing: 
[checkbox name="airway" value="normal|slow|shallow|fast|deep|labored|respiratory distress|respiratory failure|agonal|absent"]
PRIMARY ASSESSMENT:
- LOC:
[checkbox name="LOC" value="AOx4|AOx3|AOx2|AOx1|AOx0|person|place|time|event|appropriate for age|at baseline"]
- GCS:
Eye = [select name="eyes" value="1|2|3|4"]
Verbal = [select name="verbal" value="1|2|3|4|5"]
Motor = [select name="motor" value="1|2|3|4|5|6"]
TOTAL: [text name="GCS" default=" "]
- Airway: [checkbox name="airway" value="airway open|airway patent|no airway obstructions|airway positioned to open|airway not patent|obstructions to airway|requires airway adjunct|requires advanced airway|requires assisted 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|not breathing spontaneously|irregular respirations|inadequate respirations|inadequate tidal volume|apparent life threats to breathing"][text name="breathing" default=" "]
- Circulation: [checkbox name="circulation" value="normal and without concerns|regular and normal pulse rate|irregular|tachycardic |bradycardic|weak pulse|massive hemorrhage|diminished perfusion| pulseless"][text name="circulation" default=" "]

- Constitutional: [checkbox name="ros_constitutional_check" value="no fever|no chills|no weakness|no fatigue|fever|chills|weakness"][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|chest pain|palpitations|swelling of extremities."][text name="ros_cardio" default=" "]
- Respiratory:[checkbox name="ros_resp_check" value="no SOB|no hemoptysis|hemoptysis|SOB"][text name="ros_resp" default=" "]
- GI: [checkbox name="ros_gi_check" value="no change in appetite|no abdominal pain|no hematemesis|change in appetite|no N/V/D|ABD 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|urinary frequency|urinary urgency|dysuria|hematuria|leakage of urine."][text name="ros_gu" default=" "]
- Musculoskeletal : [checkbox name="ros_msk_check" value="no back pain|no joint pain|no muscle aches|no generalized muscle pain|no neck pain|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|no wounds|rash|bruising|lesions|itching|wounds"][text name="ros_skin" default=" "]
- Neuro: [checkbox name="ros_neuro_check" value="no headache|no dizziness|no syncope|no LOC|headache|dizziness|syncope|ALOC"][text name="ros_neuro" default=" "]
- Psych: [checkbox name="ros_psych_check" value="denies Suicide ideation/homicide ideation|no hallucination|no depression|no anxiety|suicide ideation\homicide ideation|hallucinations|depressed|anxious"][text name="ros_psych" default=" "]
- Endocrine: [checkbox name="ros_endo_check" value="no excessive thirst|no polyuria|excessive thirst|polyuria"][text name="ros_endo" default=" "]
- Hematologic: [checkbox name="ros_heme_check" value="no excessive bruising|no excessive bleeding|excessive bruising|excessive bleeding"][text name="ros_heme" default=" "]

PHYSICAL ASSESSMENT:
- ETCO2:[text name="CO2" default=" "]
- BGL:[text name="pe_bgl" default=" "]
- EKG Findings: [checkbox name="EKG" value="Sinus Rhythm|Sinus Bradycardia|Sinus Tachycardia|Sinus Arrhythmia|Wandering Atrial Pacemaker|Multifocal ATach|AFIB|AFIB w/RVR|Supraventricular Tachycardia|Aflutter|Junctional Rhythm|First Degree AV Block|Second Degree Type 1|Second Degree Type 2|3rd Degree Block|IVR|Accelerated IVR|VTach|VFib|Asytole|PEA|Torsades|w/PVC's|w/PAC's|w/PJC's"][text name="ros_heme" default=" "]
- 12 Lead Findings: [text name="CC" size = 45 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|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=" "]
- HEENT: [checkbox name="pe_heent_check" value="normocephalic|atraumatic|PERRLA|white sclera|conjuntiva 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|trauma to face|trauma to mouth"][text name="pe_heent" 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|wheezing|rhonchi|rales|stridor|upper respiratory congestion"][text name="pe_resp" default=" "]
- GI:[checkbox name="pe_gi_check" value="atrumatic|BS present in all 4 quadrants|abdomen soft/non-tender to palpation|distended|no distention|rigidity|no rigidity|guarding|no guarding|no masses"][text name="pe_gi" 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=" "]
- MSK: [checkbox name="pe_msk_check" value="normal Range of movement|no pain on palpation|strength 5/5 in all extremities|abnormal range of motion|pain on palpation|strength not present in all extremities|obvious deformities"][text name="pe_msk" default=" "]
- Neuro: [checkbox name="pe_neuro_check" value="Grossly oriented X 4|gait normal|sensation intact|normal reflexes|smile normal|speech not slurred|neuro not grossly intact|gait abnormal|sensation absent|no reflexes|smile not symmetrical|slurred speech|at baseline"][text name="pe_neuro" default=" "]
- Psych: [checkbox name="pe_psych_check" value="pleasant, calm and cooperative|judgement and insight intact|understands treatment|thought process normal|normal affect|unpleasant|not calm|not cooperative|does not understand treatment|at baseline"][text name="pe_psych" default=" "]
- Hematologic: [checkbox name="pe_heme_check" value="no tenderness or masses palpated|no bruises|no bleeding|tenderness/masses|bruising|bleeding."][text name="pe_heme" default=" "]

PRIMARY IMPRESSION: [text name="PI" size = 55 default=" "]
SECONDARY IMPRESSION: [text name="SI" size = 55 default=" "]

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

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