EMT PCR Basic

Incident:[textarea name="incident" default=" EMT responded to medical call for "]

Upon Arrival: [textarea name="ptinfo" default=" On arrival EMT "]

Complaints: [textarea name="Chiefcomplaint" default=" "]

Onset: [text name="O" size = 55 default=" "]

Additional Signs/Symptoms Reported: [textarea name="s" size = 55 default=" "]

Allergies: [text name="a" size = 55 default="NKDA"]
Medications: [text name="m" size = 55 default=""]
Past Med Hx: [text name="p" size = 55 default=""]
History of present illness: [textarea name="e" size = 55 default=" "]
Other Hx Info: [textarea name="hpi" default=" "]

Assessment: 
General/Overall Appearance:  [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=" "]
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="airway" size = 55 default=" "]
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="airway" size = 55 default=" "]
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=" "]
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=" "]
HEENT: [checkbox name="head" value="normal and atraumatic. |no reported pain. |nupils equally round and reactive."]
Neck: [checkbox name="neck" value="normal and atraumatic. |JVD. |no JVD. |tracheal deviation. |no tracheal deviation. |no reported pain."][text name="neck" size = 55 default=" "]
Chest: [checkbox name="chest" value="normal and atraumatic. |breath sounds clear equal bilaterally. |no reported pain."][text name="chest" size = 55 default=" "]
Back: [checkbox name="back" value="normal and atraumatic. |no reported pain."][text name="back" size = 55 default=" "]
Abdomen: [checkbox name="abdomen" value="soft, non-tender, and atraumatic. |no pain. "][text name="abdomen" size = 55 default=" "]
Pelvis: [checkbox name="pelvis" value="normal and atraumatic. |no reported pain. "][text name="pelvis" size = 55 default=" ]
Extremities: [checkbox name="extremities" value="normal and atraumatic. |equal strength x4. |unequal strength. |cap refill less than 2 seconds. |no reported pain. "][text name="extremities" size = 55 default=" "]
Additional Assessment Findings: [textarea name="additassess" default=" "]
Vital Signs:
HR:    [text name="0" default="BPM"]
RR:    [text name="0" default="BPM"]
BP:    [text name="0" default="mmHg"]
BGL:    [text name="0" default="mg/dl"]
SPO2:[text name="0" default="%"]   

Rx:
Treatment included: [checkbox name="treatment" value="primary and secondary BLS assessment. |airway    adjunct placed. |oxygen administered. |AED used. |CPR performed. |first aid/wound care. |Assisted ventilations with BVM.|suction used. |cervical collar placed.|topical wound care applied"] [textarea name="rxt" default=" "]

TRANSPORT: [checkbox name="pe_trans_check" value="Pt transported by EMS. |WorkCare recommended pt go to uregent care. |Pt returned to work. |Not transported.
"][textarea name="pe_trans" default=" "]

Destination:
[checkbox name="dest" value="Urgent Care. |Returned to work. |Transported by EMS. |ER."]
[textarea name="destcheck" default=""]

Narrative: [textarea name="variable_1" default=""]

Provider: 
[text name="prov" size = 45 default=" "]
[checkbox name="care" value="EMT."]
Incident:


Upon Arrival:


Complaints:


Onset:

Additional Signs/Symptoms Reported:


Allergies:
Medications:
Past Med Hx:
History of present illness:

Other Hx Info:


Assessment:
General/Overall Appearance:

Airway:
Breathing:
Circulation:
Level of Consciousness:
SKIN:
HEENT:
Neck:
Chest:
Back:
Abdomen:
Pelvis:
Extremities:
Additional Assessment Findings:

Vital Signs:
HR:
RR:
BP:
BGL:
SPO2:

Rx:
Treatment included:


TRANSPORT:


Destination:



Narrative:


Provider:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.33, 49 form elements, 56 boilerplate words, 21 text boxes, 12 text areas, 16 checkboxes, 124 total clicks
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