ESO Narrative

[textarea name="ATA" default="***All times in this narrative or elsewhere in this chart are approximate***"]

[comment memo="History of Present Illness"]

Patient is a/an [text name="PtAge"] YO [checkbox value="Male|Female"] with a chief complaint of "[text name="CC"]" for the past [text name="CCduration"] [checkbox name="ccdurtioninterval" value="minutes|hours|days|weeks|months|years"]. [textarea name="HPIstmt" default="Patient states...  ...called 911."]

[comment memo="Scene Description"]

Arrived on scene and made contact with [checkbox name="whodafuk" value="Pt's family member|a bystander|LEO|Fire Dept. personnel|a home healthcare provider|facility staff"] who led crew to Patient.  Found Patient [checkbox name="position" value="standing|sitting|lying supine|lying prone|lying in the LLR position|lying in the RLR position"] [checkbox name="inoron" value="on the floor|on the ground|in a chair|in a wheelchair|in a recliner|on a sofa|on the steps|in the driver's seat|in the passenger seat|in the back seat|in bed|in a hospital bed"] in the [checkbox name="area" value="master bedroom|front bedroom|back bedroom|living room|kitchen|dining room|garage|bathroom|shed|patients room|right shoulder|left shoulder|middle|retail area|break room|storage area|office|cab|passenger compartment|front|back|parking lot|entryway"] of the [checkbox name="largerarea" value="residence|business|store|facility|vehicle|building|park|roadway|street|house|waterway"]; [checkbox name="AO" value="alert|responsive to verbal stimuli|responsive to painful stimuli|unresponsive|oriented,|confused,|puleselss|apneic,"] and [checkbox name="Distress" value="not in any obvious distress|in mild distress|in moderate distress|in severe distress|in emotional distress|agitated|combative"]. 

[comment memo="Did you perform assessment of Patient?"]
[checkbox name="assmt2" value="Performed primary and secondary assessment while obtaining HPI."]

[comment memo="Spinal motion restriction assessment/application."]
[checkbox name="nsaids" value="Neurologic exam yields no findings of focal deficits, Pt is alert and oriented normally, and no signs of intoxication or distracting injuries are identified. Pt reports no pain on flexion, extension, rotation, or palpation of spinal processes, and no step-off or deformities are noted."][checkbox name="spinalmotion" value="Applied spinal motion restriction per protocol."]

[comment memo="Pt walked to unit."]
[checkbox name="walktounit" value="Assisted Pt in walking to and entering unit.  Patient laid down on stretcher and crew secured Patient with all appropriate safety restraints. "][checkbox name="benchseat" value="Assisted Pt in walking to and entering unit.  Patient sat down on bench seat and donned all appropriate safety restraints."]

[comment memo="Assisted Patient to stretcher."]
[checkbox name="assisttostretcher" value="Assisted Patient in moving to stretcher.  Secured Patient to stretcher and moved to unit.  Loaded Pt on stretcher into unit and secured. "]

[comment memo="Moved Patient to stretcher via..."]
[checkbox name="stairchair" value="Moved patient to stretcher via stairchair.  Secured Patient to stretcher and moved to unit.  Loaded Pt on stretcher into unit and secured. "][checkbox name="reevesstretcher" value="Moved patient to stretcher via Reeve's stretcher.  Secured Patient to stretcher and moved to unit.  Loaded Pt on stretcher into unit and secured. "][checkbox name="megamover" value="Moved patient to stretcher via Megamover.  Secured Patient to stretcher and moved to unit.  Loaded Pt on stretcher into unit and secured. "]

[comment memo="Refusal After Assessment"]
[checkbox name="refuseafterassmt" value="Explained exam findings to Pt who indicated understanding.  Pt expressed to crew that they did not wish to be further assessed, treated, or transported by EMS to the ED.  Explained risks of refusing transport to Pt who indicated understanding and still wished to refuse.  Explained refusal and AOB forms to Pt who indicated understanding and signed both forms in the appropriate fields.  Re-iterated risks of refusing assessment, treatment, and transport to Pt and again offered those to Pt who still refused.  Explained to Pt that if they change their mind about accepting EMS that they can call 911 again at any time and Pt indicated understanding.  Cleared scene.  Available."]

[comment memo="Refusal Without Assessment"]
[checkbox name="refusenoassmt" value="Pt expressed to crew that they did not wish to be assessed, treated, or transported by EMS to the ED.  Explained risks of refusing transport to Pt who indicated understanding and still wished to refuse.  Explained refusal and AOB forms to Pt who indicated understanding and signed both forms in the appropriate fields.  Re-iterated risks of refusing assessment, treatment, and transport to Pt and again offered those to Pt who still refused.  Explained to Pt that if they change their mind about accepting EMS that they can call 911 again at any time and Pt indicated understanding.  Cleared scene.  Available."]

[comment memo="Transport"]
[checkbox name="transportnoprob" value="Transported Pt to ED without incident."]
[checkbox name="transporttraumagreen" value="Transported Pt to ED, activating trauma green while enroute."]
[checkbox name="transporttraumayellow" value="Transported Pt to ED, activating trauma yellow while enroute."]
[checkbox name="transporttraumared" value="Transported Pt to ED, activating trauma red while enroute."]
[checkbox name="transportSTEMI" value="Transported Pt to ED, activating CODE STEMI while enroute."]
[checkbox name="transportSTROKE" value="Transported Pt to ED, activating CODE STROKE while enroute."]

[comment memo="ED Arrival"]

Arrived at hospital and unloaded Pt from unit.  Entered hospital where staff directed crew to Tx room [text name="txroom"]. [checkbox name="movetobedh" value="With assistance of staff, moved patient from stretcher to bed using a draw sheet.|Moved patient from stretcher to bed using a draw sheet.|Assisted patient in sliding from stretcher to bed.|Patient stood and walked to bed.|Patient stood and pivoted to bed."]

[comment memo="Report"]
[checkbox name="Report" value="Gave verbal and written report to trauma team.|Gave verbal and written report to stroke team.|Gave verbal and written report to ED nurse.|Gave verbal and written report to ED physician and ED nurse."]

[comment memo="Signatures"]
[checkbox name="signatures" value="ED nurse signed PCR, transferring Pt care.|ED nurse signed PCR and AOB (due to patient's altered mental status, transferring Pt care.|ED nurse signed PCR and stroke form, transferring Pt care."]

Out of county mileage: [text name="ocm"] Miles

[comment memo="------->Required Text for Other sections of PCR<--------"]

[comment memo="IV Starts"]

[checkbox name="ivsuccess" value="Using aseptic technique, initiated IV access in order to administer IV medications.  No extravasation noted.  Lung sounds noted clear bilaterally prior to, during, and after administration.|Using aseptic technique, attempted IV access in order to administer IV medications.  The attempt was unsuccessful due to extravasation and discontinued."]

[comment memo="EKG Interpretation"]

Findings:
-Rate: [text size="5"] bpm [checkbox value="- normal"]
-Predominant Rhythm: [checkbox name="rhythm" value="sinus rhythm"] [conditional field="rhythm" condition="(rhythm).isNot('sinus rhythm')"][checkbox value="sinus bradycardia|sinus tachycardia|atrial fibrillation|pacemaker rhythm|other"]. [text memo="explanation" memo_size="small" size="80"][/conditional]
-Axis: [checkbox name="axis" value="normal"][conditional field="axis" condition="(axis).isNot('normal')"][checkbox value="L Axis Deviation|R Axis Deviation|Indeterminate"]. [text memo="explanation" memo_size="small" size="80"][/conditional]
-Blocks: [checkbox name="blocks" value="none"][conditional field="blocks" condition="(blocks).isNot('none')"][checkbox value="1st degree AV block|2nd degree mobitz type 1 AV block|2nd degree mobitz type 2 AV block|3rd degree/complete AV block|R Complete BBB|R Incomplete BBB|L Complete BBB|L Incomplete BBB|L Anterior Hemiblock|L Posterior Hemiblock"][/conditional]
-P Wave morphology: [checkbox name="pwave" value="normal/uniform"][conditional field="pwave" condition="(pwave).isNot('normal/uniform')"][text memo="explanation" memo_size="small" size="80"][/conditional]
-QRS complex: [checkbox name="qrs" value="normal width/morphology"][conditional field="qrs" condition="(qrs).isNot('normal width/morphology')"][text memo="explanation" memo_size="small" size="80"][/conditional]
-R wave progression: [checkbox name="rwave" value="normal|POOR"]
-T wave morphology- [checkbox name="twave" value="normal"][conditional field="twave" condition="(twave).isNot('normal')"][checkbox value="flattened.|inverted.|peaked."] [text memo="explanation" memo_size="small" default="affected leads-" size="80"][/conditional]
-QTc interval- [checkbox name="qtc" value="normal"][conditional field="qtc" condition="(qtc).isNot('normal')"][checkbox value="borderline|prolonged"][/conditional]
-PR segment(s)- [checkbox name="prseg" value="normal"][conditional field="prseg" condition="(prseg).isNot('normal')"][checkbox value="elevated.|depressed."] [text memo="explanation" memo_size="small" default="affected leads-" size="80"][/conditional]
-ST segment(s)- [checkbox name="stseg" value="normal"][conditional field="stseg" condition="(stseg).isNot('normal')"][checkbox value="elevated.|depressed."] [text memo="explanation" memo_size="small" default="affected leads-" size="80"][/conditional]

Comparison: [checkbox name="comparison" value="no interval change|no prior EKG to compare"][conditional field="comparison" condition="(comparison).isNot('no interval change')&&(comparison).isNot('no prior EKG to compare')"] [text memo="explanation" memo_size="small" size="80"][/conditional]

Interpretation/Conclusion: [checkbox name="interpretation" value="normal EKG."] [textarea memo="explanation if needed" memo_size="small"]





History of Present Illness

Patient is a/an YO with a chief complaint of "" for the past .


Scene Description

Arrived on scene and made contact with who led crew to Patient. Found Patient in the of the ; and .

Did you perform assessment of Patient?


Spinal motion restriction assessment/application.


Pt walked to unit.


Assisted Patient to stretcher.


Moved Patient to stretcher via...


Refusal After Assessment


Refusal Without Assessment


Transport







ED Arrival

Arrived at hospital and unloaded Pt from unit. Entered hospital where staff directed crew to Tx room .

Report


Signatures


Out of county mileage: Miles

------->Required Text for Other sections of PCR<--------

IV Starts



EKG Interpretation

Findings:
-Rate: bpm
-Predominant Rhythm:
-Axis:
-Blocks:
-P Wave morphology:
-QRS complex:
-R wave progression:
-T wave morphology-
-QTc interval-
-PR segment(s)-
-ST segment(s)-

Comparison:

Interpretation/Conclusion:
explanation if needed



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.75, 93 form elements, 85 boilerplate words, 14 text boxes, 3 text areas, 50 checkboxes, 16 comments, 10 conditionals, 171 total clicks
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