BCEMS TRANSPORT CHART (INTERFACILITY, LZ)

C - DISPATCHED EC [text name="variable_1" default=""] [select name="variable_2" value="EMERGENCY TRAFFIC|NON- EMERGENCY TRAFFIC"] to [text name="variable_2" default=""] FOR AN [select name="variable_3" value="INTERFACILITY TRANSPORT|HOSPITAL LZ TRANSPORT"] FROM THIS FACILITY TO [text name="variable_3" default=""]. EMS RESPONDED WITH [select name="variable_4" value="LIGHTS AND SIREN|NO LIGHT OR SIREN"] USING DUE REGARD TO LIFE SAFETY.

H - THE PT CAME TO [text name="variable_2" default=""] COMPLAINING OF [textarea name="variable_1" 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="variable_3" 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="variable_1" value="CARDIOLOGY|PULMONOLGY|NEWBORN|GASTROINTESTINAL|NEUROLOGY|ORTHOPEDIC|PREGNANCY|PSYCH|RADIOLOGY|REHAB|DIALYSIS|TRAUMA|WOUND CARE|OTHER|"] [text name="variable_5" default=""] 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|DEMENITA|PARKENSON'S DISEASE|A-FIB|DECUBITIS ULCERS "] [text name="variable_6" default=""]. THE PT HAS ALLERGIES TO [checkbox name="variable_2" value="PCN|SULFA|AMOXICILLIN|ASPIRIN|CODEINE"] [text name="variable_7" default=""]. THE PT TAKES VARIOUS MEDS WHICH ARE LISTED IN THE EPCR REPORT.
A- UPON ARRIVAL TO [text name="variable_2" default=""] STAFF GAVE REPORT AND THE PT WAS FOUND IN ROOM [text name="variable_8" default=""]. THE PT IS FOUND TO BE ALERT AND ORIENTED X [text name="variable_9" default=""] WITH A GCS OF [text name="variable_10" default=""]. THE PT SKIN IS [checkbox name="variable21" value="WARM, DRY AND NORMAL COLOR|WARM|COOL|COLD|PALE|DRY|CYANOTIC|MOTTLED|JAUNDICED"] [text name="variable_11" default=""]. THE PT HAS [checkbox name="variable22" value="BILATERAL RADIAL PULSES PRESENT|PEDAL PULSES PRESENT |ABSENT RADIAL PULSES|ABSENT PEDAL PULSES|UNILATERAL RADIAL PULSE PRESENT |UNILATERAL PEDAL PULSE PRESENT|BILATERAL BRACHIAL PULSES PRESNET|UNILATERAL BRACHIAL PULSE PRESENT"][text name="variable_12" 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="BREATHING" 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="CIRCULATION" 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 UNREMARKABLE. |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 UNREMARKABLE. |JVD. |NO JVD. |TRACHEAL DEVIATION. |NO TRACHEAL DEVIATION. |NO REPORTED PAIN."][text name="NECK" size = 55 default=" "]
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=" "]
ABDOMEN: [checkbox name="ABDOMEN " value="SOFT, NON-TENDER, UNREMARKABLE. |NO PAIN. "][text name="ABDOMEN" size = 55 default=" "]
PELVIS: [checkbox name="PELVIS" value="NORMAL AND UNREMARKABLE. |NO REPORTED PAIN. "][text name="PELVIS" size = 55 default=" ]
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=" "]
ADDITIONAL ASSESSMENT FINDINGS: [textarea name="additassess" default=" "]
EKG: [checkbox name="EKG" value="12 LEAD EKG |4 LEAD CARDIAC MONITORING|NORMAL SINUS RHYTHM|SINUS TACHYCARDIA|BRADYCARDIA|A-FIB|A-FLUTTER|NO ST ELEVATION OR ECTOPY. |NO EKG PREFORMED. "][text name="EKG" size = 55 default=" "]
PAIN LEVEL AT START [select name="variable_5" value="1|2|3|4|5|6|7|8|9|10"]
PAIN LEVEL AT ENDING [select name="variable_6" value="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 IN THIS CHART.  INITIAL SP02 WAS NOTED AS [text name="variable_13" default="SPO2"]%.  BREATHING RATE WAS NOTED AS [text name="variable_14" default=""] BPM. THE PT WAS PLACED ON CARDIAC MONITOR AND [select name="variable_4" value="4 LEAD|12 LEAD|OTHER"] LEAD EKG WAS OBTAINED AND READING [text name="variable_20" default=""] PT WAS CONTINUED ON 02 AT [text name="variable_15" default="02 setting"]LPM. DURING TRANSPORT THE PT WAS GIVEN [textarea name="variable_5" default="sample text"]. ONGOING ASSESSMENT WAS CONTINUED TO DURING TRANSPORT. 
THE PT WAS TRANSPORTED TO [text name="variable_3" default=""] VIA EMS COT AND SECURED WITH PROVIDED STRAPS IN FOWLERS POSITION. THE PT CONDITION [checkbox name="variable_13" value="IMPROVED|UNCHANGED|WORSE"] DURING TRANSPORT AND UPON ARRIVAL TO [text name="variable_3" default=""] THE PT WAS MOVED TO ROOM #[text name="variable_16" default=""]  BED.  PT CARE AND REPORT GIVEN TO [text name="variable_17" default=""]RN

[text name="variable_18" default="YOUR NAME"] [text name="variable_19" default="CERT #"]
C - DISPATCHED EC to FOR AN FROM THIS FACILITY TO . EMS RESPONDED WITH 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 WHICH IS NOT AVAILABLE AT SENDING FACILITY. STAFF REPORTS THE PT
. THE PT HAS A MEDICAL HISTORY OF . THE PT HAS ALLERGIES TO . THE PT TAKES VARIOUS MEDS WHICH ARE LISTED IN THE EPCR REPORT.
A- UPON ARRIVAL TO STAFF GAVE REPORT AND THE PT WAS FOUND IN ROOM . THE PT IS FOUND TO BE ALERT AND ORIENTED X WITH A GCS OF . THE PT SKIN IS . THE PT HAS .
ASSESSMENT:
GENERAL OVERALL APPEARANCE:

AIRWAY:
BREATHING:
CIRCULATION:
LEVEL OF CONSCIOUSNESS:
SKIN:
HEENT:
NECK:
CHEST:
BACK:
ABDOMEN:
PELVIS:
EXTREMITIES:
ADDITIONAL ASSESSMENT FINDINGS:

EKG:
PAIN LEVEL AT START
PAIN LEVEL AT ENDING
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 IN THIS CHART. INITIAL SP02 WAS NOTED AS %. BREATHING RATE WAS NOTED AS BPM. THE PT WAS PLACED ON CARDIAC MONITOR AND LEAD EKG WAS OBTAINED AND READING PT WAS CONTINUED ON 02 AT LPM. DURING TRANSPORT THE PT WAS GIVEN
. ONGOING ASSESSMENT WAS CONTINUED TO DURING TRANSPORT.
THE PT WAS TRANSPORTED TO VIA EMS COT AND SECURED WITH PROVIDED STRAPS IN FOWLERS POSITION. THE PT CONDITION DURING TRANSPORT AND UPON ARRIVAL TO THE PT WAS MOVED TO ROOM # BED. PT CARE AND REPORT GIVEN TO RN


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