DH RI

Dispatch: On [date name="variable_1" default=""] while on shift, crew was dispatched for [text name="tn1" default=""].  Crew responded without delay.  There were no incidents while responding.

Scene:
[textarea name="scene" default="sample text"]

Complaints: 
Upon arrival at scene, crew located the patient [textarea name="Chiefcomplaint" default=" "].  [text name="Advised" default="Patient"] advised [textarea name="variable_2" default=""].
Additional Signs/Symptoms Reported: [textarea name="s" size = 100 default=" "]

History: 
Onset: [text name="O" size = 100 default=" "]
Allergies: Obtained as noted.
Medications: Obtained as noted.
Past Medical History: Obtained as noted.
Events Surrounding Condition: [textarea name="e" size = 100 default="None Noted"]

Assessment:
Level of Consciousness: 
[checkbox name="loc" value="Alert|Oriented|Person|Place|Time|Event|Disoriented|Arousable by verbal stimuli|Arousable by painful stimuli|Unresponsive"][text name="consciousness" size = 100 default=" "]
Airway: 
[checkbox name="airway" value="Open|Maintained by patient|No concerns for compromise|Not open|Compromised |Requires manual opening|Requires airway adjunct|Requires advanced airway"][text name="airway" size = 100 default=" "]
Breathing: [checkbox name="breathing" value="Adequate tidal volume and rate. |Fast|Deep|Slow|Shallow|Apneic"][text name="airway" size = 100 default=" "]
Circulation: 
[checkbox name="circulation" value="Radial|Carotid|Brachial|Femoral|Posterior Tibial|Dorsalis Pedis|Regular and normal pulse rate bi-laterally.|Tachycardic|Bradycardic|Weak pulse|Massive hemorrhage|Diminished perfusion|Pulseless"][text name="airway" size = 100 default=" "]
SKIN: 
[checkbox name="skin" value="Pink|Warm|Dry|Pale|Cool|Clammy|Diaphoretic|Hot|Flushed|Cyanotic|Lividity|Jaundiced"][text name="skin" size = 100 default=" "]
HEENT: 
[checkbox name="head" value="No pertinent findings|No reported pain|Pupils equally round and reactive"][text name="head" size = 100 default=" "]
Neck: 
[checkbox name="neck" value="No pertinent findings|No JVD.|Trachae Midline|No reported pain"][text name="neck" size = 100 default=" "]
Chest: 
[checkbox name="chest" value="No pertinent findings|Breath sounds clear equal bilaterally|Equal chest rise|No reported pain"][text name="chest" size = 100 default=" "]
Back: 
[checkbox name="back" value="No pertinent findings|No reported pain"][text name="back" size = 100 default=" "]
Abdomen: 
[checkbox name="abdomen" value="No pertinent findings|No reported pain|Soft non-tender on palpation in all quadrants"][text name="abdomen" size = 100 default=" "]
Pelvis: 
[checkbox name="pelvis" value="No pertinent findings|No reported pain"][text name="pelvis" size = 100 default=" ]
Extremities: 
[checkbox name="extremities" value="No pertinent findings|+CSM x4|Equal grip strength x4|Cap refill less than 2 seconds|Skin pink, warm, dry|No reported pain|No Clubbing|No Edema"][text name="extremities" size = 100 default=" "]
GI/GU:
[checkbox name="variable_1" value="No pertinent findings|Dysuria|Polyuria|Diarrhea|Bloody stools"][text name=“extremities” size = 100 default=]
Psych:
[checkbox name="variable_2" value="No pertinent findings|Calm|Cooperative|No SI/HI|Suicidial ideation|Homicidal ideation.|ETOH use.|Drug use."][text name=“Drugs” size =100 default=]
Neurological: 
Gait: 
[select name="G1" value="Steady coordinated gait|Abnormal|Non-Ambulatory"]
Sensation: 
[checkbox name="Sensation" value="Intact and symmetric at upper and lower extremities bilaterally|None|Partial|Not    Done|Other"][text name="Sensation" size = 100 default=""]
Strength: 
[checkbox name="Strength" value="Intact and symmetric at upper and lower extremities bilaterally|None|Partial|Not    Done|Other"][text name="Strength" size = 100 default=""]
FAST ED Score:[select name="FastED" value="0|1|2|3|4|5|6|7|8|9|Not indicated for patients condition"]

Additional neurological findings: 
[textarea default="None Noted"]

Additional Assessment Findings: 
[textarea name="additassess" default="None Noted"]

Rx:
Treatment included: 
[checkbox name="treatment" value="BLS assessment|ALS assessment|Vital signs obtained as noted|Cardiac monitoring enroute|IV access successful|IV    access    unsuccessful"]    Medications:    [text    name="other"    size=100    default"]

TRANSPORT: 
[checkbox name="pe_trans_check" value="In the supine position|In the semi-fowlers position|Secured to stretcher via 5 seatbelts|Secured in airway seat via shoulder/lap belt.| Transported lights/sirens.|Non-Emergency.|Patient Refusal.|Patient refusal Against Medical Advise|Patient treated and released Against Medical Advise.|Cancelled on scene.|Cancelled while responding."]

Patient transported to: 
[select name="Transport" value="No    Transport|Brattleboro Memorial Hospital|Grace Cottage Hospital|Pine Heights of Brattleboro|Dartmouth Hitchcock Medical Center|Albnay Medical Center|Hartford Hospital|Springfield Hospital|Baystate Medical Center, Springfield|Baystate Medical Center, Franklin|Brattleboro Retreat|Southern VT Medical Center|The    Cheshire    Medical    Center|Yankee    Dialysis|Other"][text    name="other"    size=100    default"]
Changes During Transport:
[text    name="other"    size=100    default"]
Destination: Upon arrival at destination, patient was transferred from the [select name="tx2" value="stretcher|No    Transport"] to the [select name="tx3" value="hospital bed|Chair|Standing|No    Transport"] via [select name="tx4" value="sheet pull|stand    &    Pivot|No    Transport"].  Once on the [select 
name="tx5" value="hospital bed|bed|chair|Standing|No    Transport"], patient care was transferred to the destination staff in stable condition. 

Signatures:[checkbox name="Variable_3" value="Signature obtained from PT|Signature obtained from patients legal gaurdian or parent|Signature obtained from RN in lieu of patient due to current condition|Signature obtained from RN for patient acceptance and transfer of care"]

Crew returned in service without further incident.
Provider: Hackler,    NRAEMT


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