BCEMS TRANSPORT CHART (INTERFACILITY, LZ)

[comment memo="INITIAL PICKUP AND DESTINATION LOCATIONS ARE REQUIRED, AFTER INITIAL, REMAINDER WILL BE AUTO GENERATED"]

[comment memo="Who responded? How did you respond, immediately (unscheduled) or non-immediately (scheduled)? Where did you respond? & What did you respond for?"]
C - Dispatched BCEMS [select name="ECUNIT" value="EC-35|EC-49|EC-50|EC-51|EC-52"][select name="Responsetype" value="Emergent|Non-Emergent"] to [text name="address" default=""][comment memo="pickup location"]. 
BCEMS responded with [select name="responsemode" value="lights and siren|no lights and siren"] for an [select name="variable_3" value="interfacility transport|hospital lz transport"] from this facility to [text name="destination" default=""]. [comment memo="destination facility"] EMS responded using due regard to life safety.
H - The PT came to [text name="address" default=""] complaining of [textarea name="chiefcompalint" default="CHIEF COMPLAINT"]. After testing and exam, the pt was diagnosed with     [textarea name="variable_2" default="HOSPITAL DIAGNOSIS"]. The PT is being transferred to [text name="destination" default=""] due to the sending facility not having the capacity or capability to provide necessary care. The PT requires higher level of care and [select name="services" value="cardiology|pulmonolgy|newborn|gastrointestinal|neurology|orthopedic|pregnancy|psych|radiology|rehab|dialysis|trauma|wound care|other"] [text name="other" default=""][comment memo="other services additional to list"] which is not available at sending facility.  
Staff reports the PT [textarea name="variable_3" default="additional info and treatment from staff"]. 
The PT has a medical history of [checkbox name="variable_1" value="COPD|CHF|HTN|chronic renal failure/ckd|diabetes|cardiac arrhythmias|cardiac condition|cardiac stent|dementia|parkinson’s disease|A-Fib|A-flutter|pacemaker|blood disorder|decubitus ulcers|obesity|anxiety|depression|arthritis|asthma|bi-polar|cancer|cardiac condition|cellulitis|hepitisis|gallbladder disease|gout|kidney stones|CVA/stroke|amputee|anemia|anoxic brain injury|autistic disorder|chronic pain|drug abuse|alcohol abuse|cirrhosis of liver|colostomy|contractures|crohn’s disease|DVT|diverticulitis|edema|seizures/epilepsy|gastric bypass surgery|history of falls|thyroid disease|infectious disease|neuropathy|osteoarthritis|pneumonia|substance abuse|tremors|vertigo"] [text name="otherhistorynotlisted" default=""] [comment memo="List any other medical history not listed"] 
The PT has allergies to [checkbox name="allergies" value="PCN|Sulfa|amoxicillin|aspirin|codeine|morphine|Statins|cepro|cillins|NKDA"][text name="allergiesnotlisted” default=""]. [comment memo="List any other allergies not listed"] 
The PT takes various meds which are listed in the EPCR report.
A- Upon arrival to [text name="address" default=""] staff gave report and the PT was found [comment memo="How the PT was found"][text name="locationfound" default=""]. The PT is found to be alert and oriented X    [select name="AVPU" value="4|3|2|1"] with a GCS of [select name="GCS" value="15|14|13|12|11|10|9|8|7|6|5|4|3"]
Assessment: 
General overall appearance: [textarea name="appearance" default=""]
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=" "][comment memo="Any other conditions not listed"]
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="breathing" size = 55 default=" "][comment memo="Any other conditions not listed"]
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="circulation" size = 55 default=" "][comment memo="Any other conditions not listed"]
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=" "][comment memo="Any other conditions not listed"]
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=" "][comment memo="Any other conditions not listed"]
Capillary Refill:[checkbox name="CapillaryRefill" value="normal and unremarkable|less than 2 seconds|greater  than 2 seconds|less than 3 seconds|greater than 3 seconds"][text name="extremities" size = 55 default=" "][comment memo="Any other conditions  not listed"]
additional assessment findings:[textarea name="additassess" default=" "][comment memo="Any other conditions not listed"] 
HEENT: [checkbox name="head" value="normal and unremarkable|no reported pain|pupils equally round and reactive|pupils unequal"][text name="head" size = 55 default=""]
Neck: [checkbox name="neck" value="normal and unremarkable|jvd|no jvd|tracheal deviation|no tracheal deviation|no reported pain"][text name="neck" size = 55 default=" "][comment memo="Any    other conditions not listed"]
Chest: [checkbox name="chest" value="normal and unremarkable|breath sounds clear equal bilaterally|no reported pain"][text name="chest" size = 55 default=" "]
Back: [checkbox name="back" value="normal and unremarkable|no reported pain"][text name="back" size = 55 default=" "][comment memo="Any other conditions not listed"]
Abdomen: [checkbox name="abdomen " value="soft, non-tender, unremarkable|no pain "][text name="abdomen" size = 55 default=" "][comment memo="Any other conditions not listed"]
Pelvis: [checkbox name="pelvis" value="normal and unremarkable|no reported pain "][text name="pelvis" size = 55 default=" ][comment memo="Any other conditions not listed"]
Extremities: [checkbox name="extremities" value="normal and unremarkable|equal strength x4 |unequal strength|cap refill less than 2 seconds|no reported pain "][text name="extremities" size = 55 default=" "][comment memo="Any other conditions not listed"]
additional assessment findings:[comment memo="Any other conditions not listed"] [textarea name="additassess" default=" "]
After initial assessment,[comment memo="How    was PT moved"] [textarea name="howwasPTmoved" default=""] and placed in position of comfort then secured with provided straps and rails up and locked. Once in EMS unit, baseline vitals were obtained and recorded as:
HR:[text name="0" default=""]BPM
RR:[text name="0" default=""]BPM
BP:[text name="0" default=""]mmHg
BGL:[text name="0" default=""]mg/dl
SPO2:[text name="0" default=""]%

[checkbox memo="" name="VAC333333" value="EKG:"][comment memo="EKG  interpretation   "][conditional field="VAC333333" condition="(VAC333333).is('EKG:')"]EKG interpretation    [checkbox name="ekg" value="12 Lead EKG |4 lead Cardiac Monitoring|Normal Sinus Rhythm|Normal Sinus Rhythm with PVC|Sinus Tachycardia|Sinus Arrhythmia|Bradycardia|A-fib|A-flutter|1st Degree AV    Block|2nd  Degree type I Block|2nd Degree  type II Block|3rd Degree AV Block|LBBB|RBBB|A-Fib with RVR|Inferior AMI|Anterior AMI|Septal  AMI|Lateral AMI|No ST Elevation or ectopy.|No EKG preformed. "][text name="ekg" size = 55 default=" "][comment memo="Any other conditions not listed"].

Initial Pain level [select name="initalpain" value="0|1|2|3|4|5|6|7|8|9|10"]

After initial assessment, the PT was moved from bed to ems cot and placed in position of comfort then secured with provided straps and rails up and locked.  Once in ems unit, baseline vitals were obtained and recorded as VITAL SIGNS: 
[checkbox name="orhtovitals" value="orthstatic positive|orthstatic negative|orhtostatic normal"]

Initial Vital Signs
HR:[text name="0" default="BPM"]
RR:[text name="0" default="BPM"]
BP:[text name="0" default="mmHg"]
BGL:[text name="0" default="mg/dl"]
SPO2:[text name="0" default="%"] 

R-Treatment during transport included the following: [comment memo="ALS or BLS assessment, O2, IV, etc."][textarea name="treatments" default="treatments"].
[comment memo="Any other conditions not listed"].[/conditional]

Pain level at destination [select name="painleveldest" value="0|1|2|3|4|5|6|7|8|9|10"]

T - Ongoing assessment was continued to during transport. 
Ongoing Vital Signs:
HR:[text name="0" default=""]BPM
RR:[text name="0" default=""]BPM
BP:[text name="0" default=""]mmHg
BGL:[text name="0" default=""]mg/dl
SPO2:[text name="0" default=""]%    

The PT was transported by Ambulance via EMS cot and secured with provided straps in [select name="position" value="fowlers|semi-fowlers|supine|prone|sitting|on left    side|on Right Side"] position    to [text name="destination" default=""]. The PT condition [checkbox name="condition" value="improved|was    unchanged|got worse"] during transport and upon arrival to [text name="destination" default=""][comment memo="destination facility"] The PT was moved to room #[text name="room" default=""]  bed.
Care and report given to [text name="nursename" default="first/last name"]
[checkbox memo="" name="VAC444444" value="Medical Necessity Statement:"][comment memo="Required on all convalescent/IFT transports. Select ALL that apply."][conditional field="VAC444444" condition="(VAC444444).is('Medical Necessity Statement:')"] The patient requires ambulance transportation due to [checkbox name="" value="Inability to get up from bed without assistance, inability to ambulate, and inability to sit in a chair or wheelchair|Could be moved only by stretcher|Is confused combative, lethargic, or comatose|Is a flight risk|Moderate  /Severe pain on    movement|Danger  to self/others|Required physical or chemical restraint to prevent injury to the beneficiary or others|Had to remain immobile because of a fracture that had not been set or the possibility of a fracture|Severe vertigo causing inability to remain upright|Needed advanced airway management (ventilator dependent, apnea monitor, possible intubation needed, deep suctioning)|Required cardiac/hemodynamic monitoring|Required non-self-administered IV meds en route|Required suctioning en route per transfer instructions|Required airway control/positioning en route per transfer instructions|Required third party assistance/attendant to apply, administer or regulate oxygen en route. Does not apply to patient capable of self-administration of portable or home 02. Patient is so frail as to require oxygen assistance.|Has a condition such that patient risks injury during vehicle movement despite restraints|Has morbid obesity which requires additional personnel or equipment to handle|Has a communicable disease or hazardous material exposure and must be isolated from the public or whose medical condition must be protected from public exposure|Has an orthopedic device that requires special handling en route (backboard, halo traction, use of pins and traction)|Has severe pain aggravated by transfers or moving vehicle such that trained expertise of EMT is required. Pain is present, but is not sole reason for transport.|Required positioning special handling to avoid further injury (less than grade 2 decubiti on buttocks).|Required positioning special handling that is inappropriate in a wheelchair or standard car seat due to contractures or recent extremity fracture|DVT requiring elevation of lower extremity|Contractures|Severe muscular weakness and de-conditioned state precludes any significant physical activity|Requires a higher level of care/specialty care unit unavailable at referring facility|Requires a procedure unavailable at referring facility|Non-healded    fractures|other"][textarea name="variable_20" default="sample text"][/conditional]

[checkbox memo="" name="VAC555555" value="Authorization for Information Release:"][comment memo="Required on all transports. If the patient is unable to sign you must select the individual signing on behalf of the patient AND select the last field notating why the patient was unable to sign."][conditional field="VAC555555" condition="(VAC555555).is('Authorization for Information Release:')"] The Authorization for Information Release and Notice of Privacy Practices acknowledgement has been captured electronically by the following: [checkbox name="" value="The patient.|The patient's legal guardian.|Relative or other person who receives social security or other governmental benefits.|Relative or other person who arranges for the patient's treatment or exercise other responsibility for the patient's affairs on behalf of the patient.|Representative of an agency or institution that did not furnish the services for which payment is claimed but furnished other care, services or assistance to the patient.|The patient was unable to sign the Authorization for Information Release and Notice of Privacy Practices necessitating an authorized representative signature due to"][textarea name="variable_20" default=""][/conditional]


[comment memo="NAME AND CERT NUMBER"]
[text name="variable_18" default="YOUR NAME"] [text name="variable_19" default=""]
INITIAL PICKUP AND DESTINATION LOCATIONS ARE REQUIRED, AFTER INITIAL, REMAINDER WILL BE AUTO GENERATED

Who responded? How did you respond, immediately (unscheduled) or non-immediately (scheduled)? Where did you respond? & What did you respond for?
C - Dispatched BCEMS to pickup location.
BCEMS responded with for an from this facility to . destination facility EMS responded using due regard to life safety.
H - The PT came to complaining of
. After testing and exam, the pt was diagnosed with
. The PT is being transferred to due to the sending facility not having the capacity or capability to provide necessary care. The PT requires higher level of care and other services additional to list which is not available at sending facility.
Staff reports the PT
.
The PT has a medical history of List any other medical history not listed
The PT has allergies to . List any other allergies not listed
The PT takes various meds which are listed in the EPCR report.
A- Upon arrival to staff gave report and the PT was found How the PT was found. The PT is found to be alert and oriented X with a GCS of
Assessment:
General overall appearance:

Airway: Any other conditions not listed
Breathing: Any other conditions not listed
Circulation: Any other conditions not listed
Level of consciousness: Any other conditions not listed
Skin: Any other conditions not listed
Capillary Refill: Any other conditions not listed
additional assessment findings:
Any other conditions not listed
HEENT:
Neck: Any other conditions not listed
Chest:
Back: Any other conditions not listed
Abdomen: Any other conditions not listed
Pelvis: Any other conditions not listed
Extremities: Any other conditions not listed
additional assessment findings:Any other conditions not listed

After initial assessment,How was PT moved
and placed in position of comfort then secured with provided straps and rails up and locked. Once in EMS unit, baseline vitals were obtained and recorded as:
HR:BPM
RR:BPM
BP:mmHg
BGL:mg/dl
SPO2:%

EKG interpretation

Pain level at destination

T - Ongoing assessment was continued to during transport.
Ongoing Vital Signs:
HR:BPM
RR:BPM
BP:mmHg
BGL:mg/dl
SPO2:%

The PT was transported by Ambulance via EMS cot and secured with provided straps in position to . The PT condition during transport and upon arrival to destination facility The PT was moved to room # bed.
Care and report given to
Required on all convalescent/IFT transports. Select ALL that apply.

Required on all transports. If the patient is unable to sign you must select the individual signing on behalf of the patient AND select the last field notating why the patient was unable to sign.


NAME AND CERT NUMBER

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.38, 120 form elements, 259 boilerplate words, 44 text boxes, 10 text areas, 23 checkboxes, 10 drop downs, 30 comments, 3 conditionals, 272 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: