Dialysis Transport (TO Dialysis Center)

[comment memo="INITIAL PICKUP AND DESTINATION LOCATIONS ARE REQUIRED, AFTER INITIAL, REMAINDER WILL BE AUTO GENERATED"]
D- BCEMS [select name="ECUNIT" value="EC-35|EC-49|EC-50|EC-51|EC-52"] was requested Non-Emergent    for transport of a [select name="ptsex" value="male|female|unknown"] PT from [text name="pickup" default=""][comment memo="Pickup location"] to be transported to [text name="destination" default=""][comment memo="destination facility"] for a [select name="typeofcall" value="scheduled|non-scheduled"] transport.

C- The Patient is being transported for dialysis treatment due to chonic    renal failure requires renal    dialysis.

H-The PT has a medical history of [checkbox name="medicalhistory" value="chronic renal failure/ckd|Morbid  Obesity|COPD|CHF|Hypertension-HTN|diabetes|cardiac arrhythmias|cardiac condition|cardiac stent|dementia|parkinson’s disease|A-Fib|A-flutter|pacemaker|blood disorder|decubitus ulcers|Above knee amputation|Below knee    amputation|anxiety|depression|arthritis|asthma|bi-polar|cancer|cardiac    condition|cellulitis|hepitisis|gallbladder disease|gout|kidney stones|CVA/stroke|amputee|anemia|anoxic brain injury|autistic disorder|chronic pain|drug abuse|alcohol abuse|cirrhosis of liver|colostomy|contractures|crohn’s disease|DVT|diverticulitis|edema|seizures/epilepsy|gastric bypass surgery|history of falls|thyroid disease|infectious disease|nephropathy|osteoarthritis|pneumonia|substance abuse|tremors|vertigo"] [text name="otherhistorynotlisted" default=""].[comment memo="List any other medical history not listed"] 
The PT has allergies to [checkbox name="allergies" value="NKDA|PCN|Sulfa|amoxicillin|aspirin|codeine|morphine|Statins|cillins|baclofen|Cipro|Hydrocodone|Ibuprofen|Demerol|Dilaudid"] [text name="allergiesnotlisted” default=""]
[comment memo="List any other allergies not listed"]
The PT takes various meds which are listed in the EPCR report. 

A- Upon arrival to the PT, they are found [comment memo="Where and how was the PT found"] [textarea name="ptlocation" default=""] 
Assessment: 
General overall appearance: [comment memo="PAY ATTENTION TO THIS    BOX REMOVE WHAT IS NOT NEEDED"][textarea name="appearance" default="the patient appears well nourished, well developed, and (appears/does not appear) to be in acute distress."]
Airway: [checkbox name="airway" value="open, maintained by patient, with no concern for compromise|open|maintained by patient|no concerns for compromise|not open|compromised|requires manual opening|requires airway adjunct|requires advanced airway"][text name="airway" size = 55 default=" "][comment memo="Any other conditions not listed"]
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="breathing" size = 55 default=" "][comment memo="Any other conditions not listed"]
Circulation: [checkbox name="circulation" value="normal and without concerns|regular and normal pulse rate|tachycardic|bradycardic|weak pulse|massive hemorrhage|diminished perfusion|pulseless"][text name="circulation" size = 55 default=" "][comment memo="Any other conditions not listed"]
Level of consciousness: [checkbox name="loc" value="alert and oriented to person, place, time, and event|alert|oriented|disoriented|person|place|time|event|arousable by verbal stimuli|arousable by painful stimuli|unresponsive"][text name="consciousness" size = 55 default=" "][comment memo="Any other conditions not listed"]
Skin: [checkbox name="skin" value="pink, warm, and dry|pale, cool, and clammy|pink|warm|dry |pale|cool|clammy|diaphoretic|hot|flushed|cyanotic|lividity|jaundiced"][text name="skin" size = 55 default=" "][comment memo="Any other conditions not listed"]
Capillary Refill: [checkbox name="CapillaryRefill" value="normal and unremarkable|less than 2 seconds|greater than 2 seconds|less than 3 seconds|greater than 3 seconds"][text name="extremities" size = 55 default=" "][comment memo="Any other conditions  not listed"]
additional assessment findings: [textarea name="additassess" default=" "][comment memo="Any other conditions not listed"] 
HEENT: [checkbox name="head" value="normal and unremarkable|no reported pain|pupils equally round and reactive|pupils unequal"][text name="head" size = 55 default=""]
Neck: [checkbox name="neck" value="normal and unremarkable|JVD|no JVD|tracheal deviation|no tracheal deviation|no reported pain"][text name="neck" size = 55 default=" "][comment memo="Any    other conditions not listed"]
Chest: [checkbox name="chest" value="normal and unremarkable|breath sounds clear equal bilaterally|no reported pain"][text name="chest" size = 55 default=" "]
Back: [checkbox name="back" value="normal and unremarkable|no reported pain"][text name="back" size = 55 default=" "][comment memo="Any other conditions not listed"]
Abdomen: [checkbox name="abdomen " value="soft, non-tender, unremarkable|no pain"][text name="abdomen" size = 55 default=" "][comment memo="Any other conditions not listed"]
Pelvis: [checkbox name="pelvis" value="normal and unremarkable|no reported pain "][text name="pelvis" size = 55 default=" ][comment memo="Any other conditions not listed"]
Extremities: [checkbox name="extremities" value="normal and unremarkable|equal strength x4 |unequal strength|cap refill less than 2 seconds|no reported pain "][text name="extremities" size = 55 default=" "][comment memo="Any other conditions not listed"]
additional assessment findings: [comment memo="Any other conditions not listed"] [textarea name="additassess" default=" "]

After initial assessment, the PT was moved to ems cot by [select name="howptmoved" value="two man lift|assited|bariatric    mat|mechanical lift|"]and placed in position of comfort then secured with provided straps and rails up and locked.  Once in ems unit, baseline vitals were obtained and recorded as: 

BP:[text name="0" default=""] mmHg
HR:[text name="0" default=""] BPM
RR:[text name="0" default=""] BPM
SPO2:[text name="0" default=""] %

Initial Pain Level: [select name="initialpainscale" value="0|1|2|3|4|5|6|7|8|9|10"]

R- Treatment during transport included the following: [comment memo="ALS or BLS assessment, O2, IV, etc"][textarea name="treatments" default="treatments"].

Destination vitals were obtained and recorded as:
BP:[text name="0" default=""] mmHg
HR:[text name="0" default=""] BPM
RR:[text name="0" default=""] BPM
SPO2:[text name="0" default=""] %

Pain    level at    destination:[select name="painscale" value="0|1|2|3|4|5|6|7|8|9|10"]

T - The PT was transported by Ambulance via EMS cot and secured with provided straps to [text name="destination" default=""]in [select name="position" value="fowlers|semi-fowlers|supine|prone|sitting|on left side|on Right Side"] position. The PT condition [checkbox name="condition" value="improved|was unchanged|got worse"] during transport and upon arrival to [text name="destination" default=""][comment memo="destination facility"] The PT was moved to [text name="room" default=""].[comment memo="Location were PT was moved too"] 
Care and report given to [text name="nursename" default="first/last name"] RN

[checkbox memo="" name="VAC444444" value="Medical Necessity Statement:"] [comment memo="Required on all convalescent/IFT transports. Select ALL that apply."][conditional field="VAC444444" condition="(VAC444444).is('Medical Necessity Statement:')"] The patient requires ambulance transportation due to [checkbox name="" value="Inability to get up from bed without assistance, inability to ambulate, and inability to sit in a chair or wheelchair|Could be moved only by stretcher|Is confused combative, lethargic, or comatose|Is a flight risk|Moderate  /Severe pain on    movement|Danger  to self/others|Required physical or chemical restraint to prevent injury to the beneficiary or others|Had to remain immobile because of a fracture that had not been set or the possibility of a fracture|Severe vertigo causing inability to remain upright|Needed advanced airway management (ventilator dependent, apnea monitor, possible intubation needed, deep suctioning)|Required cardiac/hemodynamic monitoring|Required non-self-administered IV meds en route|Required suctioning en route per transfer instructions|Required airway control/positioning en route per transfer instructions|Required third party assistance/attendant to apply, administer or regulate oxygen en route. Does not apply to patient capable of self-administration of portable or home 02. Patient is so frail as to require oxygen assistance.|Has a condition such that patient risks injury during vehicle movement despite restraints|Has morbid obesity which requires additional personnel or equipment to handle|Has a communicable disease or hazardous material exposure and must be isolated from the public or whose medical condition must be protected from public exposure|Has an orthopedic device that requires special handling en route (backboard, halo traction, use of pins and traction)|Has severe pain aggravated by transfers or moving vehicle such that trained expertise of EMT is required. Pain is present, but is not sole reason for transport.|Required positioning special handling to avoid further injury (less than grade 2 decubiti on buttocks).|Required positioning special handling that is inappropriate in a wheelchair or standard car seat due to contractures or recent extremity fracture|DVT requiring elevation of lower extremity|Contractures|Severe muscular weakness and de-conditioned state precludes any significant physical activity|Requires a higher level of care/specialty care unit unavailable at referring facility|Requires a procedure unavailable at referring facility|Non-healded    fractures|other"][textarea name="variable_20" default=""][/conditional]

[checkbox memo="" name="VAC555555" value="Authorization for Information Release:"][comment memo="Required on all transports. If the patient is unable to sign you must select the individual signing on behalf of the patient AND select the last field notating why the patient was unable to sign."][conditional field="VAC555555" condition="(VAC555555).is('Authorization for Information Release:')"] The Authorization for Information Release and Notice of Privacy Practices acknowledgement has been captured electronically by the following: [checkbox name="" value="The patient.|The patient's legal guardian.|Relative or other person who receives social security or other governmental benefits.|Relative or other person who arranges for the patient's treatment or exercise other responsibility for the patient's affairs on behalf of the patient.|Representative of an agency or institution that did not furnish the services for which payment is claimed but furnished other care, services or assistance to the patient.|The patient was unable to sign the Authorization for Information Release and Notice of Privacy Practices necessitating an authorized representative signature due to"][textarea name="variable_20" default=""][/conditional]

Providers Name and license Number    [text name="variable_18" default=""] [text name="variable_19" default=""]