Critical care EPCR:

HISTORY OF PRESENT ILLNESS:

[date name="variable_1" default="05-10-2024"] WE FIND A [text name="variable_2" default=""] year old [checkbox name="variable_3" value=" Male|Female"]PATIENT PRESENTING WITH:[textarea name="variable_4" default=""]
 
CURRENT HISTORY:[textarea name="variable_4" default=""]
 
TREATMENT PRIOR TO OUR ARRIVAL:[textarea name="variable_5" default=""]

HOSPITAL MEDICATIONS:
[textarea name="Medications" default=""]
 
SENDING DOCTOR:
[textarea name="variable_6" default=""]
 
MEDICAL DIRECTOR CONTACTED: ( ) YES ( ) NO
 
HOSPITAL VENTILATOR SETTINGS;

MODE:[text name="variable_7" default=""]
FIO2:[text name="variable_8" default=""]
SAO2:[text name="variable_9" default=""]
VT:[text name="variable_10" default=""]
SET RATE:[text name="variable_11" default=""]
TOTAL RATE:[text name="variable_12" default=""]
PIP:[text name="variable_13" default=""]
ALARM H/L:[text name="variable_14" default=""]
SENSITIVITY:[text name="variable_15" default=""]
PEEP:[text name="variable_16" default=""]
 
MICU VENTILATOR SETTINGS;

MODE:[text name="variable_17" default=""]
FIO2:[text name="variable_18" default=""]
SAO2:[text name="variable_19" default=""]
VT:[text name="variable_20" default=""]
SET RATE:[text name="variable_21" default=""]
TOTAL RATE:[text name="variable_22" default=""]
PIP:[text name="variable_23" default=""]
ALARM H/L:[text name="variable_24" default=""]
SENSITIVITY:[text name="variable_25" default=""]
PEEP:[text name="variable_26" default=""]
 
TREATMENT PRIOR TO OUR ARRIVAL:[textarea name="variable_27" default=""]

LABS:

NA:[text name="variable_28" default=""]
K:[text name="variable_29" default=""]
CHLORIDE:[text name="variable_30" default=""]
C02:[text name="variable_31" default=""]
BUN:[text name="variable_32" default=""]
CREATINE:[text name="variable_33" default=""]
GLUCOSE:[text name="variable_34" default=""]
 
WBC:[text name="variable_35" default=""]
HGB:[text name="variable_36" default=""]
HCT:[text name="variable_37" default=""]
PLATELETS:[text name="variable_38" default=""]
 
VBG:[text name="variable_39" default=""]
SAO2:[text name="variable_40" default=""]
PO2:[text name="variable_41" default=""]
PCO2:[text name="variable_42" default=""]
PH:[text name="variable_43" default=""]
HCO3:[text name="variable_44" default=""]
BE:[text name="variable_45" default=""]
 
HOSPITAL VITALS:
LOC:[text name="variable_46" default=""]
BP:[text name="variable_47" default=""]
HR:[text name="variable_48" default=""]
RR:[text name="variable_49" default=""]
SpO2:[text name="variable_50" default=""]

Assessment:
GENERAL: [textarea name="appearance" default=" Interacting with EMS appropriately; well appearing; not acutely distressed. "]
CNS: [textarea name="CNS" default=" Alert and oriented to person, place, time, and situation. Cranial nerves intact with normal facial movements, visual fields, and gag reflex. Motor strength and coordination normal in all four extremities."]
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=" Extremities warm, well-perfused with intact sensation and normal range of motion. Pulses palpable and symmetric bilaterally: radial, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis. No edema or cyanosis noted. "]
SKIN: [textarea name="skin" default=" Skin warm, dry, and intact without lesions or rashes. Capillary refill less than 2 seconds in all extremities. "]
VITALS: [textarea name="vitals" default=" "]
EKG: [textarea name="ekg" default=" "]
 
POST TREATMENT CHANGES IN PATIENT CONDITION:[textarea name="variable_51" default=""]
 

PT WAS TRANSPORTED TO: TRINITY HEALTH AA IP
PATIENT CARE TURNED OVER TO RN IN ROOM #
 
PT'S PERSONAL BELONGINGS:
BELONGINGS LEFT WITH:

HISTORY OF PRESENT ILLNESS:

WE FIND A year old PATIENT PRESENTING WITH:


CURRENT HISTORY:


TREATMENT PRIOR TO OUR ARRIVAL:


HOSPITAL MEDICATIONS:


SENDING DOCTOR:


MEDICAL DIRECTOR CONTACTED: ( ) YES ( ) NO

HOSPITAL VENTILATOR SETTINGS;

MODE:
FIO2:
SAO2:
VT:
SET RATE:
TOTAL RATE:
PIP:
ALARM H/L:
SENSITIVITY:
PEEP:

MICU VENTILATOR SETTINGS;

MODE:
FIO2:
SAO2:
VT:
SET RATE:
TOTAL RATE:
PIP:
ALARM H/L:
SENSITIVITY:
PEEP:

TREATMENT PRIOR TO OUR ARRIVAL:


LABS:

NA:
K:
CHLORIDE:
C02:
BUN:
CREATINE:
GLUCOSE:

WBC:
HGB:
HCT:
PLATELETS:

VBG:
SAO2:
PO2:
PCO2:
PH:
HCO3:
BE:

HOSPITAL VITALS:
LOC:
BP:
HR:
RR:
SpO2:

Assessment:
GENERAL:

CNS:

PSYCH:

CARDIOVASCULAR:

PULMONARY:

GI/GU:


Physical Exam:
HEAD:

NECK:

CHEST:

BACK:

ABDOMEN:

PELVIS:

EXTREMITIES:

SKIN:

VITALS:

EKG:


POST TREATMENT CHANGES IN PATIENT CONDITION:



PT WAS TRANSPORTED TO: TRINITY HEALTH AA IP
PATIENT CARE TURNED OVER TO RN IN ROOM #

PT'S PERSONAL BELONGINGS:
BELONGINGS LEFT WITH:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.03, 69 form elements, 141 boilerplate words, 44 text boxes, 23 text areas, 1 dates, 1 checkboxes, 70 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: