CEMS

S:[textarea name="ptinfo" default=" EMS dispatched to above address for "]

PMHx: [checkbox name="pmhx" value="Recorded in PCR|Unable to obtain"][textarea name="pmhx" default=" "]
MEDICATIONS: [checkbox name="meds" value="Recorded in PCR|Unable to obtain"][textarea name="medications" default=" "]
ALLERGIES: [checkbox name="allergies_check" value="NKDA|Recorded in PCR"][textarea name="allergies" default=" "]

O:
-AIRWAY: [checkbox name="airway" value="Open, maintained by patient, with no concern 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="airway" size = 55 default=" "]
-CIRCULATION: [checkbox name="circulation" value="Regular and normal pulse rate |Tachycardic |Bradycardic |Weak pulse |Massive hemorrhage |Diminished perfusion |Pulseless "][text name="airway" size = 55 default=" "]
-LOC: [checkbox name="loc" value="Alert|Oriented|Person|Place|Time|Event|Altered|Alert To Verbal Stimuli|Alert To Painful Stimuli|Unresponsive"][text name="consciousness" size = 55 default=" "]
-SKIN: [checkbox name="skin" value="Warm, pink, and dry |Pale, cool, and clammy |Pink |Warm |Dry |Pale |Cool |Clammy |Diaphoretic |Hot |Flushed |Cyanotic |Lividity |Jaundiced |Rigor |Mottled"][text name="skin" size = 55 default=" "]
-HEENT: [checkbox name="head" value="Normal and atraumatic |No reported pain"][text name="head" size = 55 default=" "]
-NECK: [checkbox name="neck" value="Normal and atraumatic |JVD |No JVD |Tracheal deviation |No tracheal deviation |No reported pain"][text name="neck" size = 55 default=" "]
-CHEST: [checkbox name="chest" value="Normal and atraumatic |Breath sounds clear, equal bilaterally with equal chest rise |No reported pain"][text name="chest" size = 55 default=" "]
-BACK: [checkbox name="back" value="Normal and atraumatic |No reported pain"][text name="back" size = 55 default=" "]
-ABDOMEN: [checkbox name="abdomen" value="Soft, non-tender, and atraumatic |Pain in URQ |Pain in ULQ |Pain in LRQ |Pain in LLQ |Generalized pain "][text name="abdomen" size = 55 default=" "]
-PELVIS: [checkbox name="pelvis" value="Normal and atraumatic |No reported pain "][text name="pelvis" size = 55 default=" ]
-EXTREMITIES: [checkbox name="extremities" value="Normal and atraumatic |Equal strength x4 |Unequal strength |Cap refill less than 2 seconds |No reported pain. "][text name="extremities" size = 55 default=" "]
-NEURO:  [checkbox name="pe_neuro_check" value="PERRL|Pupils dilated|Pupils pinpoint|Slurred speech|Sensation absent|No reflexes|Smile not symmetrical|Slurred speech|Unable to assess "][text name="pe_neuro" default=" "]
[checkbox name="LAMS" value="---LAMS SCORE---"][conditional field="LAMS" condition="(LAMS).is('---LAMS SCORE---')"] 
Facial droop --> [select name="face"  value="Absent (0 points)=0|Present right side (1 point)=1|Present left side (1 point)=1"]
Arm drift --> [select name="drift"  value="Absent (0 points)=0|Slow drift (1 point)=1|Falls rapidly (2 points)=2"]
Grip strength -->[select name="grip"  value="Normal (0 points)=0|Weak on right side (1 point)=1|Weak on left side (1 point)=1|Absent (2 points)=2"]

---TOTAL SCORE---
-----> [calc value="(face)+(drift)+(grip)" memo="score"] <-----
[/conditional]
[checkbox name="Additfindings" value="ADDITIONAL FINDINGS"][conditional field="Additfindings" condition="(Additfindings).is('ADDITIONAL FINDINGS')"] 
[textarea name="variable_1" default=""]
[/conditional]
VITALS:
BP:[text name="pe_bp" default=" "], PULSE:[text name="pe_pulse" default=" "], RESP: [text name="Resp" default=" "], SPO2:[text name="pe_spo2" default=" "], BGL:[text name="pe_bgl" default=" "], TEMP:[text name="TEMP" default=" "]
-EKG FINDINGS: [checkbox name="EKG" value="4 Lead ECG obtained|& 12 Lead ECG obtained|Manual interpretation|Computer interpretation|STEMI|Sinus Rhythm|Paced Rhythm|Sinus Bradycardia|Sinus Tachycardia|Sinus Arrhythmia|Wandering Atrial Pacemaker|Multifocal Atrial Tachycardia|A-Fib|A-Fib w/ RVR|Supraventricular Tachycardia|Atrial Flutter|Junctional Rhythm|RBBB|LBBB|First Degree AV Block|Second Degree Type 1|Second Degree Type 2|3rd Degree Block|IVR|Accelerated IVR|V-Tach|V-Fib|Asystole|PEA|Torsades|w/ PVC's|w/ PAC's|w/ PJC's "][text name="ros_heme" default=" "]

A: [text name="assessment" default=""]

P:
[checkbox name="pe_trans_check" value="Secured patient to stretcher with 5 straps and rails upright|Loaded into ambulance for transport|Emergent|Non-emergent|Non-emergent upgraded to emergent|Patient refused transport|AMA|Transported to Miriam|Transported to Landmark|Transported to Rhode Island Hospital|Transported to Hasbro|Transported to VA, prior notice given|Transported to Roger Williams|Transported to Sturdy|per patient request|per family request|per CEMS crew member discretion as closest facility|per Med Control recommendation"][checkbox name="variable_1" value="Hospital    notified    via    Patient    Tracking    Systems|Hospital    notifed    via    Cellular"]
[checkbox name="treatment" value="Primary and secondary ALS assessment|Primary and secondary BLS assessment|Continuous cardiac monitoring "] [textarea name="rxt" default=" "]
[checkbox name="pe_rep_check" value="Verbal report to nurse|Patient belongings left with nurse|Patient belongings left with patient/family|Improvement in patient condition|Decline in patient condition|No change in patient condition "][text name="pe_rep" default=" "]

[checkbox name="AMA" value="---AMA---"][conditional field="AMA" condition="(AMA).is('---AMA---')"] 
EMS performed an evaluation of the patient to the extent permitted. Efforts were made to encourage the patient to consent to continued EMS evaluation, treatment, and transport to the hospital for further assessment.

The patient was found to be alert and oriented to person, place, time, and event (AOx4), not under the influence of drugs or alcohol, of legal age, and able to make competent decisions. Despite persistent efforts by EMS, the patient firmly declined further evaluation, treatment, and transport against medical advice.

EMS informed the patient of the potential risks associated with refusal of care, including but not limited to, death and/or disability. The patient acknowledged understanding of these risks but maintained their decision to refuse. The patient was advised that they are free to call 911 if their condition worsens or if they decide to seek transport to the emergency department for further evaluation and treatment.
[/conditional]