31E2 ACR

Incident:[textarea name="incident" default=" 31E2 was dispatched to "]

Upon Arrival: [textarea name="ptinfo" default=" On arrival crew encountered a "]

Complaints: [textarea name="Chiefcomplaint" default=" "]

Complaint 
Onset: [text name="O" size = 55 default=" "]

Additional Signs/Symptoms Reported: [textarea name="s" size = 55 default=" "]
Allergies: [text name="a" size = 55 default=" See demographics "]
Medications: [text name="m" size = 55 default="See demographics "]
Past Med Hx: [text name="p" size = 55 default="See demographics "]
History of present illness: [textarea name="e" size = 55 default=" "]
Other Hx Info: [textarea name="hpi" default=" "]

Assessment: 
General/Overall Appearance:  [textarea name="appearance" default=" The patient appears well nourished, well developed, and appears/does not appear to be in acute distress. "]
Airway: [checkbox name="airway" value="open, maintained by patient, with no concern for compromise |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="Breathing spontaneously, non-labored, with a regular rate and adequate tidal volume. |tachypneic. |deep. |bradypneic. |shallow. |agonal. |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 and oriented to person, place, time, and event. |alert. |oriented. |disoriented. |Person. |Place. |Time. |Event. |arousable by verbal stimuli. |arousable by painful stimuli. |unresponsive."][text name="consciousness" size = 55 default=" "]
SKIN: [checkbox name="skin" value="pink, warm, and dry. |pale, cool, and clammy. |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="Pupils PERRL at Xmm "]
Neck: [checkbox name="neck" value="normal and atraumatic. |JVD. |no JVD. |Tracheal deviation. |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="soft, non-tender, 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 strength x4. |unequal strength. |cap refill less than 2 seconds. |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=" "]
Vital Signs: [checkbox name="variable_1" value="Orthostatic positive. |Orthostatic negative. "]

Field Dx/Protocol: 
[textarea name="variable_1" default="sample text"]

Rx:
Treatment included: [checkbox name="treatment" value="primary and secondary ALS assessment. |cardiac monitoring enroute. |Waveform capnography monitored enroute. |IV access. |IO access. |Oxygen administered. |QC pads placed. |CPR performed with metronome. |Res-Q-pod used. |Res-Q-pump used. |assisted ventilations with BVM. "] [textarea name="rxt" default=" "]

TRANSPORT: [checkbox name="pe_trans_check" value="The patient was secured to the stretcher with all rails and straps. |Transported semi-fowler. |Transported high fowler. |Transported fowler position. |Transported in Trendelenburg's position. |Transported left lateral recumbent. | Transported on LSB. |Refusal AMA with OLMC consult. |Refusal AMA w/o OLMC consult.
"][textarea name="pe_trans" default=" "]

Destination: [checkbox name="dest" value="BROOK |SBH    |DOWNS |WMC |KCH |LICH |LUTHR |MAIMO |METHO |INTER |WYCOF |NYCOM |BIHWY |MAIBR |BKLNH |Not transported. "]
[textarea name="destcheck" default=" "]

Hospital Activations: [checkbox name="activations" value="Stroke Activation. |Trauma Activation. |Sepsis Activation. |STEMI Activation. |CPR Activation. |Security requested. |No activation. |Not transported. "][text name="pe_act" default=" "]

Changes During Transport: [checkbox name="changes" value="No acute changes during transport. |Patient remains stable. |Patient's condition improved during transport. |Not transported. "] [textarea name="rxt" default=" "]

Hospital Arrival: [checkbox name="hosparrival" value="Upon arrival at ER handoff is given to nurse/provider at bedside. |Nurse signs PCR. |Patient signs PCR. |Patient unable to sign due to AMS. |TOC Paramedic signs PCR. |Patient unable to sign due to physical impairment. |Not transported. "][textarea name="pe_trans" default=" "]

Additional Notes: 
[textarea name="variable_1" default=" No additional."]

Provider: 
[text name="prov" size = 45 default=" "]
[checkbox name="care" value="EMT-P. |EMT. |AEMT. |EMT-I"]
Incident:


Upon Arrival:


Complaints:


Complaint
Onset:

Additional Signs/Symptoms Reported:

Allergies:
Medications:
Past Med Hx:
History of present illness:

Other Hx Info:


Assessment:
General/Overall Appearance:

Airway:
Breathing:
Circulation:
Level of Consciousness:
SKIN:
HEENT:
Neck:
Chest:
Back:
Abdomen:
Pelvis:
Extremities:
Additional Assessment Findings:

EKG:
Vital Signs:

Field Dx/Protocol:


Rx:
Treatment included:


TRANSPORT:


Destination:


Hospital Activations:

Changes During Transport:


Hospital Arrival:


Additional Notes:


Provider:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.38, 55 form elements, 64 boilerplate words, 19 text boxes, 15 text areas, 21 checkboxes, 173 total clicks
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