DCHART 2022

Emergency Medical Services
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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. "]
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=" Transport non-emergent to HOSPITAL with pre-arrival notification made enroute. During transport patient remains stable."]

HOSPITAL ARRIVAL: [textarea name="hosp" default=" Upon arrival at ED handoff given to nurse and provider at bedside. Nurse signs PCR. Patient signs PCR. "]

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.*"]
Incident/Dispatch:

Upon Arrival:

Hx:
PMH, Rx, Allergies Noted-
Other Hx Info:

Assessment:
GENERAL:
CNS:
PSYCH:
CARDIOVASCULAR:
PULMONARY:
GI/GU:
HEAD:
NECK:
CHEST:
BACK:
ABDOMEN:
PELVIS:
EXTREMITIES:
SKIN:
VITALS:
EKG:



TREATMENT:

TRANSPORT:

HOSPITAL ARRIVAL:

No further care.

-

Result - Copy and paste this output:

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