BHCor EMS DCHART

Incident/Dispatch:[textarea name="incident" default=" "]
Upon Arrival: [textarea name="ptinfo" default=" "]
Hx: PMH, Rx, Allergies Noted- [textarea name="e" size = 55 default=" "]
Other Hx Info: [textarea name="otherhx" default=" "]

Assessment:
GENERAL: [textarea name="appearance" default=" Interacting with EMS appropriately; well appearing; not acutely distressed. "]
CNS: [textarea name="CNS" default=" Speech is not slurred; CMS grossly intact in all 4 extremities; gait is steady. "]
PSYCH: [textarea name="psych" default=" No reported recent or active suicidality or homicidal ideations. No reported recent or active visual/auditory disturbances. "]
CARDIOVASCULAR: [textarea name="cardiovascular" default=" No immediate concerns. Equal radial pulses bilaterally. "]
PULMONARY: [textarea name="PULM" default=" No initial immediate concerns. Normal and adequate tidal volume and respiratory drive. "]
GI/GU: [textarea name="GIGU" default=" No nausea or vomiting. No changes in bowel reported. No changes in urine reported. "]

Physical Exam:
HEAD: [textarea name="head" default=" No noted pain or trauma. Pupils equally round/reactive at 4mm in size. No facial droop. "]
NECK: [textarea name="NECK" default=" No noted pain or trauma. No JVD. No midline pain. "]
CHEST: [textarea name="chest" default=" No noted pain or trauma. Equal rise and fall. Breath sounds CTA bilaterally. "]
BACK: [textarea name="back" default=" No noted pain or trauma. "]
ABDOMEN: [textarea name="abd" default=" No noted pain or trauma. Soft, flat, non-tender. "]
PELVIS: [textarea name="pelvis" default=" No noted pain or trauma. Stable. "]
EXTREMITIES: [textarea name="extremities" default=" No noted pain or trauma. No clubbing, cyanosis or edema. "]
SKIN: [textarea name="skin" default=" Normal tone, warm, dry. "]
VITALS: [textarea name="vitals" default=" "]
EKG: [textarea name="ekg" default=" "]

TREATMENT: 
[textarea name="treatment" default=" "]

TRANSPORT: 
[textarea name="TPU" default=" Transported to facility with pre-arrival notification made enroute. During transport patient remains stable."]

DESTINATION ARRIVAL:
[textarea name="hosp" default=" Upon arrival at destination handoff given and care transfered. "]

No further care.
-

[checkbox name="Student" value="*Some assessments and procedures were performed by paramedic student who was under my direct supervision as the attending paramedic, and consistent with student's scope of practice.*"]
[checkbox name="Disclaimer" value="*Please note that this dictation was completed with computer voice recognition software. Oftentimes unanticipated grammatical, syntax, homophones, and other interpretive errors are inadvertently transcribed by the computer software. Please disregard these errors. Please excuse any errors that have escaped final proofreading.*"]
Incident/Dispatch:

Upon Arrival:

Hx: PMH, Rx, Allergies Noted-

Other Hx Info:


Assessment:
GENERAL:

CNS:

PSYCH:

CARDIOVASCULAR:

PULMONARY:

GI/GU:


Physical Exam:
HEAD:

NECK:

CHEST:

BACK:

ABDOMEN:

PELVIS:

EXTREMITIES:

SKIN:

VITALS:

EKG:


TREATMENT:


TRANSPORT:


DESTINATION ARRIVAL:


No further care.
-


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.08, 25 form elements, 40 boilerplate words, 23 text areas, 2 checkboxes, 25 total clicks
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