ALS Chart in a Big Red Truck

Medic[text name="variable_1" default=""]dispatched    [text name="variable_1" default="[checklist name="variable_1" value="emergent|nonemergent]to[select name="variable_1" value="private    residence|mobile    home    |apartment    complex|local    buisness"]for[text name="variable_1" default="sample text"].Upon    arrival,crew was    greeted    by    [select name="variable_1" value="husband|wife|son|daughter|mother|father|PD|FD|bystander|buisness    owner|neighbor|pt"],and    was    informed    that[text name="variable_1" default="sample text"].    

Pt    was    discovered[select name="variable_1" value="outside|inside"],[select name="variable_1" value="on    lawn|in    chair|on    couch|in    bed|on    floor    |in    living    room|in    kitchen"][textarea name="variable_1" default="sample text"],   [select name="variable_1" value="sitting|standing|supine|left    lateral    recumbant|right    lateral    recumbant|prone
"],    and    was    noted    to    be    [select name="variable_1" value="breathing|apneic|cyanotic|"][textarea name="variable_1" default="sample text"].Pt    states    that    [textarea name="variable_1" default="sample text"].

Assessment    of    the    face    reveals    [checklist name="variable_1" value="no    bleeding|no    bruising|no    newly    missing    teeth|no    deformity    to    nose|"].Eyes    are    noted    to    be    [checklist name="variable_1" value="equal|roud|reactive    to    light|2mm|3mm|4mm|5mm|discongugate|fixed    and    dilated|unequal|abnormal"]
Assessment    of    the    head    and    neck    reveal    [checklist name="variable_1" value="bleeding|bruising|tracheal    deviation|stridor    upon    inhalation|bleeding    to    the    ears|cervical    deformity|"]
Assessment    of    the    chest    reveals    [checklist name="bleeding|bruising|flail    chest|pacemaker|lung    sounds    clear    and    equal    bilaterally|adventitous    lung    sounds|puncture    wound|PICC    line|"]
Assessment    of    the    extremities   reveal   [checklist name="variable_1" value="BKA|bleeding|bruising|missing    digits|swelling|edema|pitting    edema|"]
Pt   [select name="variable_1" value="is|is    not"]found    to    be    incontinent    of    bowel    or    bladder.    [checklist name="variable_1" value="Pelvis    is    stable|Pelvis    is    unstable|Pelvis and    posterior    not    assessed"]

Pt    endorses    pain    to    [textarea name="variable_1" default="sample text"].

[checklist name="variable_1" value="Pt    states    they    would    like    to    be    transported    |    Pt    declines    transport    at    this    time|IV    initiated|VSS|    Cardiac    monitoring    initiated|Analgesia    administered|Antiemetics    administered|Cardiac    medications    administered|    TCP    administered|Pt    defiribilated|Pt    declined    care    or    interventions    at    this    time,    stating    that|"]

[select name="variable_1" value="Husband|Wife|Sister|Brother|Parent|Neighbor|Friend|"]present    on    scene    during    encounter    with    pt.    Pt    [select name="variable_1" value="did|did    not"] show    signs    of    fear    or    discomfort    ,[select name="variable_1" value="often    reaching    out    for    support    and    clarification| often    declining    to    speak    in    their    presence"].Pt    is    noted    to    be    [checklist name="variable_1" value="dressed    appropriately    for    weather|dressed    inappropriately    for    weather|and    intended    event|disheveled|well    kept|    appears    as    if    hygiene    is    being    neglected|does    not    appear    as    if    hygiene    is    being    neglected"].Speech    is    [checklist name="variable_1" value="organized|rapid|disorganized"],and    pt   [select name="variable_1" value="struggles|does    not    struggle"]with    orientation    questions    regarding    [checklist name="variable_1" value="self|place|time|long    term    event|short    term    event|"]
Medicdispatched tofor.Upon arrival,crew was greeted by ,and was informed that.

Pt was discovered,
, , and was noted to be
.Pt states that
.

Assessment of the face reveals .Eyes are noted to be
Assessment of the head and neck reveal
Assessment of the chest reveals
Assessment of the extremities reveal
Pt found to be incontinent of bowel or bladder.

Pt endorses pain to
.



present on scene during encounter with pt. Pt show signs of fear or discomfort ,.Pt is noted to be .Speech is ,and pt with orientation questions regarding

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.72, 29 form elements, 90 boilerplate words, 4 text boxes, 4 text areas, 10 check lists, 11 drop downs, 82 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: