AFRD EMS PCR

S: 
[textarea name="variable_1" default="Engine ## was dispatched to xxx for a/an ## age male/female with a cc of xxx."]

Medical Hx:[checkbox name="variable_1" value="no medical history"]
[textarea name="variable_1" default="sample text"]

ALLERGIES:[checkbox name="allergies_check" value="NKDA"]
[textarea name="variable_1" default="sample text"]

O:
- INITIAL ABC's:
AIRWAY: [checkbox name="airway" value="NORMAL, AIRWAY OPEN AND PATENT|AIRWAY POSITIONED TO OPEN|AIRWAY OBSTRUCTED|REQUIRES AIRWAY ADJUNCT|REQUIRES ADVANCED AIRWAY|REQUIRES ARTIFICIAL VENTILATION|REQUIRES AIRWAY SUCTIONING"]
OTHER:[text name="airway" default=" "]

-BREATHING: [checkbox name="breathing" value="NORMAL, RATE, RHYTHM AND TIDAL VOLUME|IRREGULAR RESPIRATIONS|INADEQUATE RESPIRATIONS|INADEQUATE TIDAL VOLUME|APNEIC"]
OTHER:[text name="breathing" default=" "]

-CIRCULATION: [checkbox name="circulation" value="NORMAL,NO OBVIOUS BLEEDING, PULSES PRESENT, SKIN COLOR APPROPRIATE|NO LIFE THREATS TO CIRCULATION|HEMORRHAGE PRESENT|HEMORRHAGE CONTROLLED|ARTERIAL TOURNIQUET APPLIED|PULSES ABSENT|SKIN COLOR NOT APPROPRIATE|LIFE THREATENING CONCERNS WITH CIRCULATION"]
OTHER:[text name="ros_constitutional" default=" "]

LEVEL OF CONSCIOUSNESS: [checkbox name="loc" value="ALERT AND ORIENTED|PERSON|PLACE|TIME |EVENT|DISORIENTED|AROUSABLE BY VERBAL STIMULI|AROUSABLE BY PAINFUL STIMULI|UNRESPONSIVE"][text name="consciousness" size = 55 default=" "]

INITIAL VITAL SIGNS
BLOOD PRESSURE: [text name="pe_bp" default=" "]
PULSE: [text name="pe_pulse" default=" "]
RESP: [text name="Resp" default=" "]
SPO2: [text name="pe_spo2" default=" "]
TEMP: [text name="TEMP" default=" "]
CO2: [text name="CO2" default=" "]
BGL: [text name="pe_bgl" default=" "]
GCS: [text name="variable_1" default="sample text"]
EKG FINDINGS: [checkbox name="EKG" value="NORMAL SINUS RHYTHM|SINUS BRADYCARDIA|SINUS TACHYCARDIA|SINUS ARRHYTHMIA|AFIB|AFIB W/RVR|SVT|ATRIAL FLUTTER|JUNCTIONAL RHYTHM|FIRST DEGREE AV BLOCK|SECOND DEGREE TYPE 1|SECOND DEGREE TYPE 2|3RD DEGREE BLOCK|IVR|ACCELERATED IVR|VTach|VFIB|ASYSTOLE|PEA|TORSADES|"][text name="ros_heme" default=" "]

PHYSICAL ASSESSMENT:
-GENERAL: [checkbox name="pe_general_check" value="WELL DEVELOPED, WELL NOURISHED, AND WELL APPEARING|NO ACUTE DISTRESS|MALNOURISHED|MODERATE DISTRESS"]

-HEENT: [checkbox name="pe_heent_check" value="NORMOCEPHALIC, ATRAUMATIC, PUPPILS PERRL, WHITE SCLERA, CONJUNCTIVA PINK, EARS PATENT, NORMAL MUCOUS AND PHARYNX|NO BLEEDING, TRAUMA TO FACE OR MOUTH|BLEEDING|POSITIVE HALO TEST|NEGATIVE HALO TEST|DRY MUCOUS MEMBRANES|EXTRA SALIVATION|TRAUMA TO FACE|TRAUMA TO MOUTH"]
OTHER:[text name="pe_heent" default=" "]

-CARDIOVASCULAR: [checkbox name="pe_cardio_check" value="REGULAR RATE AND RHYTHM, PERIPHERAL PULSES PRESENT, CAP REFILL <3 SECS|IRREGULAR RATE|IRREGULAR RHYTHM|NO PERIPHERAL PULSES|CYANOSIS PRESENT|BLEEDING"]
OTHER:[text name="pe_cardio" default=" "]

-RESPIRATORY: [checkbox name="pe_resp_check" value="CLEAR IN ALL FIELDS, NO RALES, RHONCHI, WHEEZES, STRIDOR, RETRACTIONS, OR ACCESSORY MUSCLE USE|WHEEZING|RALES|RHONCHI|STRIDOR|UPPER RESPIRATORY CONGESTION"]
OTHER:[text name="pe_resp" default=" "]

-GI: [checkbox name="pe_gi_check" value="ATRAUMATIC, BOWEL SOUNDS PRESENT IN ALL 4 QUADRANTS, ABDOMEN SOFT/NON-TENDER TO PALPATION|NON-DISTENDED OR RIGID, NO GUARDING, NO MASSES|TRAUMA PRESENT|TENDER ABDOMEN|RIGID ABDOMEN|DISTENDED ABDOMEN|GUARDING PRESENT|MASSES PRESENT"]
OTHER:[text name="pe_gi" default=" "]

-MSK: [checkbox name="pe_msk_check" value="NORMAL RANGE OF MOTION, WITHOUT PAIN ON PALPATION,PMS NOTED IN ALL EXTREMITIES|ABNORMAL RANGE OF MOTION|PAIN ON PALPATION|STRENGTH NOT PRESENT IN ALL EXTREMITIES|UNABLE TO ASSESS"]
OTHER:[text name="pe_msk" default=" "]

-SKIN: [checkbox name="pe_skin_check" value="PINK|WARM|DRY|PALE|COOL|CYANOTIC|FLUSHED|CLAMMY|HOT"]
OTHER:[text name="pe_skin" default=" "]

-NEURO: [checkbox name="pe_neuro_check" value="GROSSLY ORIENTED X 4, GAIT NORMAL, SENSATION INTACT WITH NORMAL REFLEXES, SMILE NORMAL, AND SPEECH NOT SLURRED|NEURO NOT GROSSLY INTACT|GAIT ABNORMAL|SENSATION ABSENT|NO REFLEXES|SMILE NOT SYMMETRICAL|SLURRED SPEECH|UNABLE TO ASSESS"]
OTHER:[text name="pe_neuro" default=" "]

A: POSSIBLE 

TREATMENT: [checkbox name="treatment" value="PRIMARY AND SECONDARY ASSESSMENT|IV ESTABLISHED| UNABLE TO OBTAIN IV|MEDICATION ADMINISTERED|NO MEDICATIONS GIVEN|CONTINUOUS CARDIAC MONITORING"]
IV SITE/SIZE:[text name="variable_1" default="sample text"]
MEDICATION ADMINISTERED:[text name="variable_1" default="sample text"]

OTHER:[textarea name="rxt" default=" "]

TRANSPORT
CARE TRANSFERRED TO GRADY EMS #[text name="variable_1" default="sample text"]
[checkbox name="pe_trans_check" value="SECURED PATIENT TO STRETCHER WITH CHEST AND LAP HARNESS AND RAILS  LOCKED IN UPRIGHT POSITION| ASSISTED WITH PT LOADED INTO AMBULANCE FOR TRANSPORT|PATIENT REFUSED TRANSPORT AMA|PATIENT TREATED AND RELEASED|NO TRANSPORT|LIFT ASSIST ONLY|"]
OTHER:[text name="pe_trans" default=" "]

[checkbox name="AMA" value="IN SPITE OF MULTIPLE ATTEMPTS BY PRIMARY/SECONDARY CARE PROVIDERS  TO CONVINCE THE PATIENT TO BE TRANSPORTED TO HOSPITAL FOR EVALUATION AND TREATMENT, WE HAVE UNFORTUNATELY BEEN UNSUCCESSFUL. HOWEVER, THE PATIENT HAS THE CAPACITY TO GIVE, RECEIVE, AND WITHHOLD INFORMATION. THE PATIENT VERBALIZES UNDERSTANDING OF THEIR CONDITION AND SYMPTOMS AND THAT REFUSING CARE COULD POSE SIGNIFICANT RISK TO THEIR LIFE. THE PATIENT HAS VERBALIZED THAT THEY UNDERSTAND OUR SPECIFIC TREATMENT PLAN WHICH INCLUDES TRANSPORT TO HOSPITAL, AND UNFORTUNATELY DOES NOT WISH TO BE TRANSPORTED AND UNDERSTANDS WITHOUT THIS TREATMENT MAY CAUSE WORSENING OF CONDITION OR DEATH. THE PATIENT UNDERSTANDS THEY ARE FREE TO CALL 911 IF CONDITION WORSENS AND THEY FEEL THEY WISH TO BE TRANSPORTED TO EMERGENCY DEPARTMENT FOR FURTHER EVALUATION AND TREATMENT."]
S:


Medical Hx:


ALLERGIES:


O:
- INITIAL ABC's:
AIRWAY:
OTHER:

-BREATHING:
OTHER:

-CIRCULATION:
OTHER:

LEVEL OF CONSCIOUSNESS:

INITIAL VITAL SIGNS
BLOOD PRESSURE:
PULSE:
RESP:
SPO2:
TEMP:
CO2:
BGL:
GCS:
EKG FINDINGS:

PHYSICAL ASSESSMENT:
-GENERAL:

-HEENT:
OTHER:

-CARDIOVASCULAR:
OTHER:

-RESPIRATORY:
OTHER:

-GI:
OTHER:

-MSK:
OTHER:

-SKIN:
OTHER:

-NEURO:
OTHER:

A: POSSIBLE

TREATMENT:
IV SITE/SIZE:
MEDICATION ADMINISTERED:

OTHER:


TRANSPORT
CARE TRANSFERRED TO GRADY EMS #

OTHER:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.39, 46 form elements, 64 boilerplate words, 24 text boxes, 4 text areas, 18 checkboxes, 149 total clicks
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