6201Narrative

Dispatch: 
On [date name="IncDate" default=""], crew was dispatched for a report of a [text name="IncDisp" default=""].  Crew responded [select name="IncResp" value="emergency with lights and sirens|non-emergency with no lights or sirens"]. During response, [select name="IncDel" value="there were no incidents during responding|there were minor delays in response due to road conditions|crew was cancelled by dispatch"].

Scene/Complaint: 
Upon arrival at scene, crew donned appropriate PPE and located the patient [text name="PtLocation" default=""].  Patient appeared [checkbox name="pe_general_check" value="well developed, well nourished"].  [text name="PerState" default="Patient"] advised [textarea name="PTAD" default="    "].

HPI:
Onset: [text name="CC" size = 55 default=" "]
Events Surrounding Condition: [textarea name="e" size = 55 default="None Noted"]
Additional Signs/Symptoms Reported: [text name="addition" default="None Noted"]
Other PERTINENT Hx: [text name="variable_1" default="None Noted"]

Assessment:
Level of consciousness: [checkbox name="loc" value="Alert|Oriented|Person|place|time |event|baseline mental status for patient"]
AIRWAY: [checkbox name="airway" value="maintained by pt|no concerns of compromise|airway patent|no airway obstructions"]

Breathing: [checkbox name="breathing" value="Breathing spontaneously|breathing regular|adequit tidal volume"]

Circulation: [checkbox name="circulation" value="No concerns of circulation|no obvious bleeding|radial pulses intact|skin color appropriate|no life threaths to circulation"]

HEET: [checkbox name="ros_heent_check" value="eyes PERRL|no bleeding|no trauma to face or mouth"]

Neck: [checkbox name="ros_neck_check" value="No pain noted|No Tracheal Deviation|No JVD"]

Chest: [checkbox name="pe_chest_check" value="bilateral equal rise and fall|atruamatic|no tenderness|clear to auscultation bilaterally upper/middle/lower lobes, no rales, rhonchi, wheezes, stridor, pleural rub, retractions, or accessory muscle use|no flail segment"]

Back: [checkbox name="ros_back_check" value="unremarkable back inspection, full range of motion. Patient denies back pain, lower back pain"]

Musculoskeletal: [checkbox name="ros_msk_check" value="normal range of motion without pain on palpation, no crepitus, no obvious deformity, strength age appropriate. Patient denies neck pain, generalized joint pain, generalized muscle pain/aches/cramps/weakness"]

Neuro: [checkbox name="ros_neuro_check" value="Oriented X 4, gait steady & balanced, sensation intact with normal reflexes, smile symmetrical, speech not slurred. Patient denies headache, dizziness, syncope, numbness/tingling, seizures or otherwise loss of consciousness"]

GI: [checkbox name="ros_gi_check" value="atraumatic, non-distended or rigid, no guarding, abdomen soft, non-tender to palpation, no masses, no rebound tenderness. Patient denies N/V/D, constipation, change in appetite, abdominal pain"]

GU: [checkbox name="ros_gu_check" value="No tenderness, denies leakage of urine, dysuria, hematuria, oliguria, polyuria, or increased urinary urgency"]

Psych: [checkbox name="ros_psych_check" value="Pleasant, calm, and cooperative; judgement and insight intact, understands treatment, thought process is logical/linear. Patient denies suicidal ideation, homicidal ideation, auditory or visual hallucinations, depression, or mood changes and age appropriate with normal affect"]

Treatment: 
[checkbox name="treatment" value="primary and secondary ALS assessment|Primary and secondary BLS assessment|Vital signs obtained as noted|continuous cardiac monitoring|12-lead ECG|waveform capnography|IO placed and flushed W/ NS 0.9% blood return noted|Peripheral vascular access obtained and flushed W/ NS 0.9% blood return noted, secured W/ tegaderm/tape|Medication administered as noted|Verbal report given to destination staff"]

Hospital Activations: 
[checkbox name="pe_act_check" value="Stroke Activation|Trauma Activation|Sepsis activation|STEMI Activation|CPR Activation|Security requested|None"]

Transport:
Patient was transferred to the [text name="txloc" default="stair-chair"] via [select name="transtretcher" value="stand and pivot with no assist|stand and pivot with little assistance|stand and pivot with full assist|blanket carry"].  Once on the [text name="txloc" default="stair-chair"], patient was secured with all available straps for safety.  Patient was then extricated from    [text name="extr" default="the residence"] without incident.

Patient was then transferred from the [text name="txloc" default="stair-chair"] to the [text name="txloc2" default="stretcher"] via [select name="transtretcher" value="stand and pivot with no assist|stand and pivot with little assistance|stand and pivot with full assist|blanket carry"] without incident.  Once on the [text name="txloc2" default="stretcher"], patient was secured with all available straps for safety.  Patient was placed in the [text name="ptpos" default="semi-fowlers position"] and was loaded into the ambulance.

Patient was transported to [select name="dest" value="Springfield Hospital ED|Brattleboro Memorial Hospital ED|Grace Cottage Hospital ED|Cheshire Medical Center ED|Dartmouth Hitchcock Medical Center ED"].  Crew transported [select name="Inctx" value="emergency with lights and sirens|non-emergency with no lights or sirens"]. During transport, [select name="txDel" value="there were no incidents during transport|there were minor delays in transport due to road conditions"]. 

Destination: Upon arrival at destination, patient was transferred from the [text name="tx2" default="stretcher"] to the [text name="tx3" default="hospital bed"] via [text name="tx4" default="sheet pull"] without incident.  Once on the [text name="tx5" default="hospital bed"], patient care was transferred to the destination staff in stable condition.

NPP/Signatures:[checkbox name="Variable_3" value="NPP offered and left with patient|NPP not offered due to pt condition|Signature obtained from PT|Signature obtained from patients legal gaurdian or parent|Signature obtained from RN in lieu of patient due to current condition|Signature obtained from RN for patient acceptance and transfer of care"]

Crew returned in service without further incident.
Provider: [text name="ProName" default=" "], [select name="State" value="VT|NH"]-[select name="lvl" value="EMT|AEMT|Medic"] [text name="licnum" default=" "]
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