Bruce DCHART

[radio name="variable_1" value="choice A|choice B|choice C"]
Dispatched for:[text name="variable_1" default=" "]yo [select name="variable_12" value="M|F"] PT transport [text name="variable_3" default="from "] to [select name="variable_4" value="the hospital|Pen Bay Hospital ER|Maine Medical Center|Eastern Maine Medical Center|Central Maine Medical Center|Miles Memorial Hospital|Quarry Hill|Windward Gardens|Bella Point|Woodlands|Knox Center"] due to [text name="variable_5" default=" "]. 
[select name="variable_6" value="Negative|Positive|Undetermined"] PUI.

All EMS personnel wore appropriate PPE before making contact with PT.

Nurse states: 
[textarea name="variable_7" default=" "]

Transfer orders per Doctor[text name="variable_8" default=" "]:  
     Protocols: [checkbox name="variable_9" value="EMS|ACLS|SCT"]
     Monitor: [checkbox name="variable_10" value="Cardiac|Fetal|SPO2|n/a"]
     VS q[text name="variable_11" default="15"]min
     IV: [textarea name="variable_12" default="n/a"]
     Pain control: [text name="variable_13" default="n/a"]
     Sedation: [text name="variable_14" default="n/a"]
     Oxygen: [text name="variable_15" default="n/a"]
     Other: [textarea name="variable_16" default="n/a"] 

Scene size up: [textarea name="variable_17" default=" "]

Pt has not had  fever, chills, cough, shortness of breath/difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste/smell, sore throat, congestion/runny nose, nausea/vomiting, diarrhea, or contact with possible COVID 19

Found PT [select name="variable_65" value="semi-fowler's|supine|prone|right lateral|left lateral"]  [checkbox name="variable_18" value="in bed|on floor|on ground"]. PT dressed [text name="variable_19" default="fully"]. [select name="variable_20" value="Applied face mask to PT|PT wearing face mask"]. 

PT has: [checkbox name="variable_21" value="foley cath|g IV in|pacemaker|no implanted devices"]

PT alert [checkbox name="variable_22" value="by verbal|by pain|unresponsive"].  PT oriented [checkbox name="variable_23" value="Person|Place|Time|Event|Mental status is baseline"].

Breathing: [select name="variable_24" value="
Regular|Irregular||Fast|Slow|Apneic"]. [checkbox name="variable_25" value="Non-labored|Labored|deep|Shallow"].  Pulse [select name="variable_26" value="Regular|Irregular||Tachycardic|Bradycardic|Pulseless"], [select name="variable_27" value="Strong|Weak"],  Skin [select name="variable_28" value="Pink|Pale|Ashen|Cyanotic|Flush|Jaundiced|has lividity"], [select name="variable_29" value="Warm|Hot|Cool|Cold"], [select name="variable_30" value="Dry|Clammy|Diaphoretic"] with [select name="variable_31" value="good|poor"] skin turgor.  Neuro intact [checkbox name="variable_32" value="with general weakness"].  Negative for Pain.

PT denies [checkbox name="variable_33" value="N/V/D|Dizziness|Headache|Chest discomfort"].  PT able to take a deep breath [select name="variable_34" value="without difficulty|with difficulty|with pain"].

[checkbox name="variable_35" value="Assisted PT to stair chair, secured PT to stair chair, Secured PT to stair chair with safety straps."] [select name="variable_36" value="Sheet lifted PT|walked with assistance|walked without assistance|PT stood and pivoted without assistance|Pt stood and pivoted with assistance"] to stretcher.  Covered PT with blanket.  PT [select name="variable_37" value="semi-Fowler’s|supine|right lateral|left lateral"].  Secured PT to stretcher with safety straps.  Stretcher to truck. 

Pain: 
     Onset: [text name="variable_38" default=" "]
     Provocation: [text name="variable_39" default="none"]  
     Quality: [select name="variable_40" value="sharp|achy|dispurse"][text name="variable_41" default=" "]
     Radiate: [text name="variable_42" default="none"] 
     Severity: [text name="variable_43" default="0"] of 10
     Time: [text name="variable_44" default=" "] 

[checkbox name="variable_66" value="Pt has:"] [select name="variable_45" value="negative|positive"] facial droop.  PT [select name="variable_46" value="negative|positive"] slurring speech.  PT [select name="variable_47" value="negative|positive"] arm drift.  PT gaze [select name="variable_48" value="normal|deviates to the left|deviates to the right|PEARL"].

[checkbox name="variable_67" value="Trauma assessment:"] [checkbox name="variable_49" value="No head injury|No drugs or alcohol|No neck pain|No back pain|Neuro intact|No distracting injuries in my clinical opinion"].

[checkbox name="variable_68" value="Psyche:"] [checkbox name="variable_50" value="PT calm and cooperative|No drugs or alcohol|No SI/No Homicidal ideations|Drug use|ETOH"] 
Pt safety ensured. 

Partner doffed PPE at the foot of the stretcher and returned to the cab.

[select name="variable_51" value="Non emergent|Emergent"] transport.  

BLS interventions: 
Vitals as noted.
[checkbox name="variable_52" value="BGL|Continued PT on O2 as stated above|lpm O2 via NC showing increase in SPO2|15lpm O2 via NRB showing improved change in CO level|15lpm O2 via BVM at 1 breath every 5-6sec showing improved change in CO level"]
     
ALS Interventions:
[checkbox name="variable_53" value="4-lead cardiac monitor showing at bpm|12-lead cardiac monitor showing at bpm|IV LOC successful.  No irritation noted.  Flushed easily|IV lock unsuccessful|0.4mg Nitro Tab via SL showing decrease in pain to 10 of 10|mcg Fentanyl via IVP showing decrease in pain to 10 of 10|ml of NS via IV gravity showing increase in SBP|4mg Zofran IVP showing decrease in nausea|Continued Pt on  as stated above"] 

[checkbox name="variable_69" value="HEENT:"]
[checkbox name="variable_54" value="Head atraumatic|Face intact|No pertinent findings|No reported pain|No discharge from ears/nose/mouth"]

[checkbox name="variable_70" value="Neck:"]
[checkbox name="variable_55" value="No pertinent findings|C-Spine with no pain or deformities found|No reported pain|No tracheal deviation.|No JVD"]
 
[checkbox name="variable_71" value="Chest:"]
[checkbox name="variable_56" value="No pertinent findings|Intact with symmetric rise and fall with good quality|Breath sounds clear equal bilaterally|Crackles found in lower fields|Expiratory wheezes found in upper fields|Diminished breath sounds|No reported pain upon breathing"]

[checkbox name="variable_72" value="Back:"]
[checkbox name="variable_57" value="No pertinent findings|Intact with no pain or deformities found"]

[checkbox name="variable_73" value="Abdomen:"]
[checkbox name="variable_58" value="No pertinent findings|No rigidity|No masses|No tenderness|No reported pain|Soft|No reported pain.|Distended"]


[checkbox name="variable_74" value="Pelvis:"]
[checkbox name="variable_59" value="No pertinent findings|Negative pain or discomfort during movement"]

[checkbox name="variable_75" value="Upper extremities:"]
[checkbox name="variable_60" value="Intact with no pertinent findings|Good distal pulses|Equal grip strength|Equal sensation|Equal motor functions|Weaker on the left|Weaker on the right|Cap refill less than 2 seconds|Cyanotic|No cyanosis|Bilateral edema|No edema|No reported pain"]

[checkbox name="variable_76" value="Lower extremities:"]
[checkbox name="variable_61" value="Intact with no pertinent findings|Good distal pulses|Equal strength|Equal sensation|Equal motor functions|Weaker on the left|Weaker on the right|Cyanoti.|No cyanosis|Bilateral edema|No edema|No reported pain"]

[checkbox name="variable_77" value="GI/GU:"]
[checkbox name="variable_62" value="Continent|Not continent|Stooling and voiding normal|Dysuria|Polyuria|Diarrhea|Bloody stools|No reported pain"]

Changes enroute:  No other significant findings.  Pt verbalized no complaints. 

Partner wore appropriate PPE before opening doors for stretcher. Left doors open to ambulance.

Stretcher to [select name="variable_63" value="the hospital|Pen Bay Hospital ER|Maine Medical Center|Eastern Maine Medical Center|Central Maine Medical Center|Miles Memorial Hospital|Quarry Hill|Windward Gardens|Bella Point|Woodlands|Knox Center"]. [select name="variable_64" value="Sheet lifted PT|PT stood and pivoted without assistance|Pt stood and pivoted with assistance"] to bed.  Settled PT into bed.  

Gave report and transferred care to staff.  

PT refused transport.  PT advised of the risks and to seek medical attention for any abnormal changes.  PT signed refusal form.  

Fogged and deconned entire pt compartment of truck.

MJB 18813-P
[checkbox name="variable_1" value="option A|option B|option C"]