EMS STUDENT DCHART 2024

D// [text name="ou" default="post/station"] was dispatched out to [text name="location" default="address"] in reference to a [text name="AGE" default="XX-year-old"] [select name="gender" value="male|female|unknown"] for [text name="disp" default="dispatch    coc"]. [text name="respunit" default="responding unit"] responded in [select name="respmode" value="an emergent|a non-emergent"] manner, [select name="lights" value="with the use of lights and sirens|without the use of lights and sirens"], with [select name="perstat" value="1|2|3|4"] personnel ([text name="pers" default="NRP John, NREMT Doe"]). [textarea name="ptloc" default="locating narrative, pt found, pt presentation"]

C// Patient was complaining of [text name="complaint" default="pt coc"]

H//
    S/ [textarea name="Hx_s" default="complaint narrative"]
    A/ [textarea name="Hx_a" default="allergies"]
    M/ [textarea name="Hx_m" default="medications"]
    P/ [textarea name="Hx_p" default="pertinent medical hx"]
    L/ [textarea name="Hx_l" default="last oral intake"]
    E/ [textarea name="Hx_e" default="Patient stated she had a sudden onset of flank & abdominal pain bilaterally. The patient states that there is blood in her urine & the stream was abnormal because it came out “in spurts.”"]
    *****
    O/ [textarea name="Hx_o" default="onset"]
    P/ [textarea name="Hx_p" default="provocation/pain development"]
    Q/ [textarea name="Hx_q" default="quality/description"]
    R/ [textarea name="Hx_r" default="radiation"]
    S/ [textarea name="Hx_s" default="severity"]
    T/ [textarea name="Hx_t" default="amount/time"]

A//
Appearance: [checkbox name="pe_general_check" value="well developed, well nourished, and well appearing|in no acute distress|malnourished|in acute distress|obese|appears ill|appears frail|obvious signs of death"][text name="pe_general" size = 55 default=" "]
-Airway: [checkbox name="airway" value="maintained by patient|no concerns of compromise|airway patent|no airway obstructions|compromised|airway positioned to open|airway not patent|obstructions to airway|requires airway adjunct|requires advanced airway|requires artificial ventilation"][text name="airway" size = 55 default=" "]
-Breathing: [checkbox name="breathing" value="breathing regular|adequate respirations|appropriate tidal volume|not spontaneously breathing|irregular respirations|inadequate respirations|inadequate tidal volume|breathing spontaneously|rapid|slow|deep|shallow|apneic"][text name="breathing" size = 55 default=" "]
-Circulation: [checkbox name="circulation" value="no concerns of circulation|no obvious bleeding|pulses intact|skin color appropriate|no life threats to circulation|hemorrhage present|hemorrhage controlled|arterial tourniquet applied|pulses not intact|skin color not appropriate|life threatening concerns with circulation|pulses weak|pulses bounding"][text name="ros_constitutional" size = 55 default=" "]
-Level of consciousness: [checkbox name="loc" value="alert|oriented|person|place|time |event|disoriented|arousable by verbal stimuli|arousable by painful stimuli|baseline for pt|unresponsive|unconscious|pharmacologically sedated|unresponsive, unconscious, pulseless, and apneic"][text name="consciousness" size = 55 default=" "]

-HEENT: [checkbox name="pe_heent_check" value="normocephalic, atraumatic, white sclera, conjunctiva pink/red, ears patent, supple neck, no neck swelling/lumps|eyes perrla|normal mucous|no bleeding|no trauma to face or mouth|eyes not perrla|pupils dilated|pupils constricted|positive halo test|negative halo test|dry mucous membranes|extra salivation|trauma to face|trauma to mouth|bleeding|neck swelling/lumps|glasses|contact lens|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_heent" default=" "]
-Cardiovascular: [checkbox name="pe_cardio_check" value="regular rate and rhythm without st elevation, no jugular vein distention, or edema|peripheral pulses intact, without cyanosis|irregular rate|irregular rhythm|st elevation present|jvd present|edema present|no peripheral pulses|cyanosis present|bleeding|did not assess|unable to assess|unable to assess due accurately to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_cardio" default=" "]
-Respiratory: [checkbox name="pe_resp_check" value="clear to auscultation bilaterally upper/middle/lower lobes, no rales, rhonchi, wheezes, stridor, pleural rub, retractions, or accessory muscle use|no respiratory distress|bilateral equal rise and fall|barrel chest|tachypnea|bradypnea|no flail segment|unequal chest rise and fall|flail segment|increased work of breathing|wheezing|rales|rhonchi|stridor|pleural rub|retractions|upper respiratory congestion|accessory muscle use|right upper lobe|right middle lobe|right lower lobe|left upper lobe|left lower lobe|bilaterally|artificial ventilations|did not assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_resp" default=" "]
-ABDOMEN: [checkbox name="pe_gi_check" value="atraumatic, bowel sounds present in all 4 quadrants, abdomen soft/non-tender to palpation|non-distended or rigid, no guarding, no masses|no rebound tenderness|rebound tenderness|trauma present|tender abdomen|rigid abdomen|distended abdomen|guarding present|masses present|left lower quadrant|left upper quadrant|right lower quadrant|right upper quadrant|did not assess|unable to assess due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess accurately to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_gi" default=" "]
-MSK: [checkbox name="pe_msk_check" value="normal range of motion|without pain on palpation|no crepitus|no obvious deformity|strength normal in all extremities|fine motorskills intact|abnormal range of motion|pain on palpation|strength not present|crepitus|obvious deformity|in all extremities|left upper extremity|right upper extremity|left lower extremity|right lower extremity|did not assess|unable to assess|unable to assess due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess accurately to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_msk" default=" "]
-Skin: [checkbox name="pe_skin_check" value="no rashes, skin tears, swelling, lesions, or discoloration|pink, warm, and dry, w/ good turgor|pale|cool|cyanotic|flushed|clammy|hot|warm|diaphoretic|lividity|mottling|jaundiced|skin tear|swelling|poor skin turgor|excessively dry skin"][text name="pe_skin" default=" "]
-Neuro: [checkbox name="pe_neuro_check" value="grossly oriented x 4, gait steady & balanced, sensation intact with normal reflexes, smile symmetrical, and speech not slurred|neuro not grossly intact|aphagia|aphasia|deceberate posturing|decorticate posturing|seizure activity|strength asymmetrical|gait abnormal|sensation absent|no reflexes|smile asymmetrical|hemiplegia|hemiparesis|slurred speech|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_neuro" default=" "]
-Psych: [checkbox name="pe_psych_check" value="pleasant, calm, and cooperative, judgement and insight intact, understands treatment, thought process is logical/linear and age appropriate with normal affect|has a plan made|unpleasant|not calm|uncooperative|does not have a plan|does not understand treatment|impaired attention/concentration|judgement and insight not intact|mood instability|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_psych" default=" "]

T// [textarea name="freestyletreat" default="Treatment"]

Pre-Hospital activations: [checkbox name="pe_act_check" value="Stroke Alert|Level 1 Trauma Activation|Level 2 Trauma Activation|Level 3 Trauma Activation|STEMI Alert|no alerts activated"][text name="pe_act" default=" "]

T//
[checkbox name="pe_trans_check" value="secured patient to stretcher with belts and rails|loaded into ambulance for transport w/o incident|emergency/lights and siren|non-emergency/no lights and siren|emergency downgraded to non-emergency/no lights and siren|non-emergency upgraded to emergency/lights and siren|lift assist only|pt refused ems evaluation & transport|patient refused evaluation|pt refused transport|patient treated and released|ama|per protocol|no transport required|no treatment required|no patient contact|pt pulseless, apneic on scene w/ resuscitation|pt pulseless, apneic on scene w/o resuscitation|w/ transport|w/o transport|rosc obtained|protocol requirements met, termination of cpr|obvious signs of death, considered futile|er physician order for termination|supine|low fowler's|semi-fowler's|fowler's|full fowler's/sitting|transferred care to another ems unit - ground|transferred care to another ems unit - air"] to [text name="pe_trans" default="destination"]
On arrival, we were directed to [text name="hospassign" default="Bay#"]. Patient transferred to [select name="variable_1" value="hospital bed|chair|wheelchair"] without incident.
Report: Patient care report given to RN [text name="RNname" default="sample text"] at bedside;prior to signing for patient care, they were given the opportunity to ask any questions, state any comments or address any concerns
Signatures: [checkbox name="signature" value="obtained from patient|obtained from guardian/poa|obtained from responsible party|unable to sign|law enforcement signed as|nurse signed as|ems crew signed as| representative|witness|no representative available"][text name="pe_signature" default=" "]

[text name="endunit" default="unit"] clear and returned to service.

[text name="rw" default="Provider"]
[text name="rwcert" default="Cert"]
[text name="variable_1" default="agency"]