ER CHART V1.0.1

INCIDENT: [textarea name="reaasonforvisit" default=" "]

CC: [textarea name="ChiefComplaint" default=" "]
[mark memo="SAMPLE, OPQRST, AEIOUTIPS" name="History"]
Hx: [textarea name="History" default=" "]
[mark memo="Primary, Secondary, include pertinant negatives" name="Assessment"]
ASSESSMENT:
IMPRESSION: [textarea name="appearance" default=" AOC x4; Interacting appropriately"]
VITALS: [textarea name="vitals" default=" BP: Pulse: Spo2: RR:"]
SKIN: [textarea name="skin" default=" Normal tone, warm, dry."]
CNS: [textarea name="CNS" default=" Speech is not slurred; CMS intact in all 4 extremities; eyes PERRL."]
PSYCH: [textarea name="psych" default=" Baseline."]
CARDIOVASCULAR: [textarea name="cardiovascular" default=" Equal radial pulses bilaterally."]
PULMONARY: [textarea name="PULMONARY" default=" Normal and adequate tidal volume and respiratory drive."]
GI/GU: [textarea name="GIGU" default=" No nausea or vomiting. No changes in bowel reported. No changes in urine reported."]
EKG: [textarea name="ekg" default=" "]
[mark memo="each intervention, who, when, time, dosage, route, reaction, etc" name="treatment"]
TREATMENT: [textarea name="treatment" default=" "]
[mark memo="destination, mode, release of care" name="transport"]
CONTINUATION OF CARE: [textarea name="COC" default=" "]