Long PCR 1

Response: [checkbox name="Response" value="Responded Priority 1|Responded Priority 2|Responded Priority 3"]

Unit responding: [text name="variable_1" default=""]

Dispatch reason: [textarea name="Response reason" default=" "]

Arrived: [checkbox name="ARRIVED" value="On scene w/o incident and no change in response mode|Cancelled en-route|Cancelled on-scene"] Applied PPE of [checkbox name="PPE" value="Gloves|Gown|Goggles/Face shield|surgical mask|N95|Respirator"]

Patient 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=" "]

Initial ABC's:
AIRWAY: [checkbox name="airway" value="maintained by pt|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 ventillation"][text name="airway" size = 55 default=" "]

Breathing: [checkbox name="breathing" value="Breathing spontaneously|breathing regular|adequate respirations|appropriate tidal volume|not spontaneously breathing|irregular respirations|inadequate respirations|inadequate tidal volume|rapid|slow|deep|shallow|apneic"][text name="breathing" size = 55 default=" "]

Circulation: [checkbox name="circulation" value="No concerns of circulation|no obvious bleeding|radial pulses intact|skin color appropriate|no life threaths to circulation|hemorrhage present|hemorrhage controlled|CAT tourniquet applied|pulses not intact|skin color not appropriate|life threatening concern with circulation present|pulses weak|bounding radial pulses"][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 mental status for patient|unresponsive|unconscious|unresponsive, unconscious, pulseless, and apneic"][text name="consciousness" size = 55 default=" "]

Psych: [checkbox name="ros_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 up|unpleasant|not calm|uncooperative|does not have a plan|does not understand treatment|impaired attention/concentration|judgement and insight not intact|mood instability|denies suicidal ideation, homicidal ideation, auditory or visual hallucinations, depression, or mood changes|Affirms -|Suicidal ideation|homicidal ideation|Auditory hallucinations|visual hallucinations|mood changes|distracted|unhappy|agitated|apathy|anxious|worries|dissassociative|upset|tearful|fearfullness|did not assess|unable to assess|unable to assess due to uncooperative state"][text name="ros_psych" default=" "]

CC: [text name="CC" size = 55 default=" "]

HPI: [text name="CC" size = 55 default=" "]
Additional Signs/Symptoms Reported: [textarea name="s" size = 55 default=" "]
Events Surrounding Condition: [textarea name="e" size = 55 default=" "]
Other PERTINENT Hx: [textarea name="hpi" default=" "]

Review of systems:

Constitutional: [checkbox name="ros_constitutional_check" value="denies -|fever|chills|weakness|fatigue|weight loss|age related muscular atrophy|senescence|frailty|affirms - |fever|chills|weakness|fatigue|weight loss|frailty|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess due to uncooperative state"][text name="ros_constitutional" default=" "]

HEET: [checkbox name="ros_heent_check" value="normocephalic, atraumatic, white sclera, conjunctiva pink/red, ears patent|eyes PERRL|normal mucous|no bleeding|no trauma to face or mouth|eyes not PERRL|pupils dilated|pupils constricted|bleeding|dry mucous membranes|hypersalivation|trauma to face|trauma to mouth|glasses|contact lenses|denies - facial pain, vision changes, eye irritation, ear pain, nasal congestion|affirms -|vision changes|eye irritation|ear pain|nasal congestion|facial pain|did not assess|unable to assess|unable to assess accurately due to altered mentat state|unable to assess due to uncooperative state"][text name="ros_heent" default=" "]

Neck: [checkbox name="ros_neck_check" value="pliable neck|no neck swelling/lumps/lumps|bleeding|trauma to neck|neck swelling/lumps|JVD|tracheal deviation - left|tracheal deviation - right|denies - sore throat, neck pain, throat congestion or cough|affirms -|sore throat|throat congestion|cough|neck pain|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess due to uncooperative state"][text name="ros_neck" default=" "]

Chest: [checkbox name="pe_chest_check" value="bilateral equal rise and fall|concave chest - normal|bleeding|atruamatic|no tenderness|tenderness|barrel chest|clear to auscultation bilaterally upper/middle/lower lobes|no rales, rhonchi, wheezes, stridor, pleural rub, retractions, or accessory muscle use|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|no flail segment|unequal chest rise and fall|flail segment|denies - shortness of breath, hemoptysis, orthopnea, dyspnea on exertion, chest pain or discomfort, palpitations, or swelling of extremities|affirms - |chest pain/discomfort|palpitations|swelling of extremities|shortness of breath|dyspnea on exertion|chest pain/discomfort|palpitations|hemoptysis|orthopnea|dyspnea|apneic|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess due to uncooperative state"][text name="pe_chest" default=" "]

GI: [checkbox name="ros_gi_check" value="atraumatic, non-distended or rigid, no guarding|bowel sounds present in all quadrants|abdomen soft, non-tender to palpation, no masses, no rebound tenderness|rebound tenderness|trauma present|tender abdomen|rigid abdomen|distended abdomen|guarding present|masses present|generalized|left lower quadrant|left upper quadrant|right ower quadrant|right upper quadrant|denies - N/V/D, constipation, change in appetite, dysphagia, abdominal pain, melena, hematochezia or hematemesis|affirms -|change in appetite|abdominal pain|hematemesis|melena|hematochezia|dysphagia|nausea|vomiting|diarrhea|constipation|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess due to uncooperative state"][text name="ros_gi" default=" "]

GU: [checkbox name="ros_gu_check" value="stable gait|no tenderness|fecal incontinence|denies - leakage of urine, dysuria, hematuria, oliguria, polyuria, or increased urinary urgency|denies sexual dysfunction|denies fecal incontinence|affirms -|sexual dysfunction|abnormal genital discharge|increased urinary frequency|foley placed|increased urinary urgency|dysuria|oliguria|hematuria|leakage of urine|pelvic tenderness|unstable gait|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess due to uncooperative state"][text name="ros_gu" default=" "]

Musculoskeletal: [checkbox name="ros_msk_check" value="normal range of motion|without pain on palpation|no crepitus|no obvious deformity|strength age appropriate|abnormal range of motion|pain on palpation|strength not present|crepitus|contractures present|asthenia|obvious deformity|in all extremities|left upper extremity|right upper extremity|left lower extremity|right lower extremity|denies - neck pain, generalized joint pain, generalized muscle pain/aches/cramps/weakness|affirms -|neck pain|generalized joint pain|generalized muscle aches|generalized muscle pain|generalized muscle cramps|generalized muscle weakness|contractures present|asthenia|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess due to uncooperative state"][text name="ros_msk" default=" "]

Back: [checkbox name="ros_back_check" value="unremarkable back inspection|abnormal back inspection|full range of motion|abnormal range of motion|denies - back pain, lower back pain|affirms -|upper back pain|mid back pain|lower back pain|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess due to uncooperative state"][text name="ros_back" default=" "]

Skin: [checkbox name="ros_skin_check" value="no rashes, skin tears, swelling, lesions, or discoloration|pink, warm, and dry, w/ good turgor|pink|dry|pale|cool|cyanotic|flushed|clammy|hot|warm|diaphoretic|lividity|mottling|jaundiced|skin tear|swelling|poor skin turgor|excessively dry skin|denies - skin pain, numbness, tingling, discoloration, swelling, rash, bruising, lesions, skin breaks, sensitivity or itching|affirms -|rash|bruising|lesions|skin pain|numbness|tingling|discoloration|sensitivity|swelling|skin breaks|itching|unable to assess due to altered mental state|unable to assess accurately due to altered mental state"][text name="ros_skin" default=" "]

Neuro: [checkbox name="ros_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|decerebrate posturing|decorticate posturing|seizure activity|strength asymmetrical|gait abnormal|sensation absent|no reflexes|smile asymmetrical|hemiplegia|hemiparesis|slurred speech|obtunded|denies - headache, dizziness, syncope, numbness/tingling, seizures or otherwise loss of consciousness|denies focal deficits|affirms -|focal deficits|incoordication|memory deficits|headache|dizziness|obtunded|syncope|numbness/tingling|loss of consciousness|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess due to uncooperative state"][text name="ros_neuro" default=" "]

Treatment: [checkbox name="treatment" value="primary and secondary ALS assessment|Primary and secondary BLS assessment|continuous cardiac monitoring|12-lead ECG|active external cooling of patient|active external warming of the patient|cervical collar placed|long spine board|waveform capnography|airway suction technique W/ yankauer|bag valve mask ventillation|CPR|obtained orthostatic vital signs|vagal stimulation|wound care|Res-Q-Pump assisted chest compressions|IO placed and flushed W/ NS 0.9% blood return noted|Peripheral vascular access placed and flushed W/ NS 0.9% blood return noted, secured W/ tegaderm/tape"] [textarea name="rxt" default=" "]

Hospital Activations: [checkbox name="pe_act_check" value="Stroke Activation|Trauma Activation|Sepsis activation|STEMI Activation|CPR Activation|Security requested|no activation"][text name="pe_act" default=" "]

Transport from scene: [checkbox name="pe_trans_check" value="Priority 1|Priority 3|Priority 1 downgraded to P3|Priority 3 upgraded Priority 1|lift assist only|pt refused EMS evaluation and transport|Pt refused evaluation|pt refused transport|Pt treated and released|AMA|FOS consult|OMD consult|per protocol|no transport required|no treatment required|no patient contact|pt pulseless, apneic on scene w/ pre-arrival CPR|pt pulseless, apneic on scene W/O pre-arrival CPR|W/ transport|W/O transport|ROSC obtained|protocol requirements met for termination of resuscitation|obvious signs of death, considered futile|Physician/OMD order for termination|Transferred care to other EMS - ground|Transferred care to other EMS - air|report called to receiving facility during transport"][text name="pe_trans" default=" "]

Mobility on scene: [checkbox name="pe_mobil1_check" value="pt able to ambulate to stretcher|pt moved to stretcher via draw-sheet method|pt placed on stretcher using lift and carry techniques|pt placed on stretcher via LSB|W/O assistance|W/ assistance|W/O incident or expression of pain/discomfort|W/ pain/discomfort expressed|patient secured to the stretcher with all rails and straps|supine position|low fowlers position|semi-fowlers position|fowlers position|sitting|loaded in to ambulance for transport W/O issue"][text name="pe_mobil1" default=" "]

Mobility at destination: [checkbox name="pe_dest_check" value="pt able to ambulate from stretcher to ED cot|pt moved from stretcher to ED cot via draw-sheet|pt moved from stretcher to ED cot via LSB|W/O assistance|W/ assistance|W/O incident|pt condition improved|pt condition declined|no change in pt condition|pt belongings left with nurse|verbal report communicated to nurse"][text name="pe_dest" default=" "]

Signatures: [checkbox name="SIGNATURE" value="obtained from patient|obtained from guardian/POA|obtained from responsible party|patient refused to sign|patient unable to sign|obtained from law enforcement|obtained from nurse/staff|EMS crew signed|witness signed|nurse signed for patient|Unable to obtain signatures"][text name="pe_signature" default=" "]

[checkbox name="AMA" value="Despite multiple attempts by myself and my partner to convince the patient (and/or responsible party) to be transported to the hospital for further evaluation and treatment, the patient remains adamant that they do not want to go. The patient/guardian is oriented, clear of mind, and has the capacity to understand the presented information. This patient/guardian has verbalized full understanding of their symptoms, and understand that forgoing further evaluation and/or treatment could pose a significant medical risk to the patient's life. The patient/guardian has verbalized that they understand our treatment plan, including interventions and transport destination, and does not want these interventions at this time. Furthermore, the patient/guardian acknowledges that forgoing this treatment could lead to worsening of condition up to and including death. The patient/guardian understands that they are free to call 911 should the patient's condition worsen, or they later decide that they wish to be transported to the Emergency Department for further evaluation and intervention. EMS also ensured that the patient/guardian was aware of other resources available such as contacting their Primary Care Provider, or visiting Urgent Care or Emergency Department on their own. The patient/guardian acknowledged these resources."]

[checklist name="variable_1" value="Mykell Ryan Buffum, NRP 80547"]

Unit responding:

Dispatch reason:

Arrived: Applied PPE of

Patient Appearance:

Initial ABC's:



Level of consciousness:



Additional Signs/Symptoms Reported:

Events Surrounding Condition:


Review of systems:












Hospital Activations:

Transport from scene:

Mobility on scene:

Mobility at destination:



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.48, 56 form elements, 59 boilerplate words, 24 text boxes, 5 text areas, 26 checkboxes, 1 check lists, 490 total clicks
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