FNCVAMC Ambulance

  [text name="referringmd" default=" " size="55"] has requested medical transport of this patient, and [text name="receivingmd" default=" " size="55"] has agreed to receive this patient in transfer. Patient is being transferred to [text name="receiving2" default=" " size="55"] for a higher level of care and [text name="specialty" default=" " size="55"] services not available at the sending facility. [text name="receiving3" default=" " size="55"] is the closest appropriate facility with both the services this patient needs, as well as an available bed.

HPI: [text name="age" default=" " size="55"]-year-old [text name="sex" default=" " size="55"] with a history of [text name="hx" default=" " size="55"] who presented to [text name="refering4" default=" " size="55"] via [text name="modeofarrival" default=" " size="55"].  Per report patient [text name="eventsleadingup" default=" " size="55"].

ER Course:  Pt was seen and evaluated by hospital staff and found to have [text name="erdiagnosis" default=" " size="55"].  Treatments as listed below and in hospital medical record.  Pt being transferred for higher level of care/services not available at sending (as noted above in HPI).  

Treatments PTA: [text name="txpta" default=" " size="55"].

Physical Exam
VS reviewed and as documented. RN notes reviewed.
Gen: [text name="gen" default="resting in bed, alert, in no acute distress" size="55"]
HEENT: [text name="heent" default="normocephalic, atraumatic, pupils PERRL" size="55"]
Neck: [text name="neck" default="Supple, trachea midline" size="55"]
CV: [text name="cards" default="Normocardic, regular, no obvious M/R/G, extremities warm, well perfused" size="55"]
Resp: [text name="resp" default="normal WOB, symmetric chest rise and fall, lungs clear" size="55"]
Abd: [text name="abd" default="Soft, non-traumatic, non-distended, no palpable organomegaly, bowel sounds present" size="55"]
MSK: [text name="msk" default="no obvious deformity, no edema, pulses 2+ bilaterally" size="55"]
GU: [text name="gu" default="Deferred" size="55"]
Rectal: [text name="rectal" default="Deferred" size="55"]
Neuro: [text name="neuro" default="Pleasant, alert, oriented" size="55"]
Skin: [text name="skin" default="warm, dry, good turgor" size="55"]

Access: 
CVL: [text name="centralvenousaccess" default="Not present" size="55"]
PIV: [text name="peripheralvenousaccess" default=" location/size,patency flushed without s/s of infiltration" size="55"]
Arterial: [text name="arterialaccess" default="Not present" size="55"]

Labs: Reviewed. Remarkable for [text name="labvalues" default=" " size="55"]. Please see hospital documentation for full details
EKG: [text name="ecg" default="Normal Sinus Rhythm with no ectopy noted" size="55"]
Imaging: [text name="imaging" default="Reviewed" size="55"] 

MDM: All labs, history, and imaging reports reviewed independently. History discussed with patient care team.  Upon review of the patient’s chief complaint, history of present complaint, past medical history, physical exam findings, diagnostic imaging results, and lab results, it is determined that the patient is experiencing [text name="diagnosismdm" default=" " size="55"] 
Appropriate PPE precautions taken. Pt attached to cardiac monitor. 
[text name="ivpump" default="Pt IV drips maintained at rates as documented above and transferred to transport IV pumps." size="55"]
[text name="ptmove" default="Pt was moved to stretcher. HOB elevated 30 degrees" size="55"]
[text name="ptmove2" default="Transfer to Ambulance uneventful." size="55"]

Transport Course: [text name="transportcourse" default="Throughout the duration of the transport..." size="55"]INITIAL ABC's:
-AIRWAY: [checkbox name="airway" value="NORMAL|AIRWAY OPEN|AIRWAY PATENT|NO AIRWAY OBSTRUCTIONS|AIRWAY POSITIONED TO OPEN|AIRWAY NOT PATENT|OBSTRUCTIONS TO AIRWAY|REQUIRES AIRWAY ADJUNCT|REQUIRES ADVANCED AIRWAY|REQUIRES ARTIFICIAL VENTILATION"][text name="airway" default=" "]
-Breathing: [checkbox name="breathing" value="NORMAL|BREATHING SPONTANEOUSLY|BREATHING REGULAR|ADEQUATE RESPIRATIONS|APPROPRIATE TIDAL VOLUME|NOT SPONTANEOUSLY BREATHING|IRREGULAR RESPIRATIONS|INADEQUATE RESPIRATIONS|INADEQUATE TIDAL VOLUME"][text name="breathing" default=" "]
-CIRCULATION: [checkbox name="circulation" value="NORMAL|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 NO APPROPRIATE|LIFE THREATENING CONCERNS WITH CIRCULATION"][text name="ros_constitutional" default=" "]REVIEW OF SYSTEMS:
-CONSTITUTIONAL: [checkbox name="ros_constitutional_check" value="NORMAL|NO FEVER|NO CHILLS|NO WEAKNESS|NO FATIGUE|FEVER|CHILLS|WEAKNESS"][text name="ros_constitutional" default=" "]
-HEENT: [checkbox name="ros_heent_check" value="NORMAL|NO VISION CHANGES|NO EAR PAIN|NO NASAL CONGESTION|NO SORE THROAT|NO COUGH"][text name="ros_heent" default=" "]
-CARDIOVASCULAR: [checkbox name="ros_cardio_check" value="NORMAL|NO CHEST PAIN|NO PALPITATIONS|NO SWELLING OF EXTREMITIES|CHEST PAIN|PALPITATIONS|SWELLING OF EXTREMITIES"][text name="ros_cardio" default=" "]
-RESPIRATORY: [checkbox name="ros_resp_check" value="NORMAL|NO SHORTNESS OF BREATH|NO HEMOPTYSIS|NO DYSPNEA|SHORTNESS OF BREATH|HEMOPTYSIS|DYSPNEA"][text name="ros_resp" default=" "]
-GI: [checkbox name="ros_gi_check" value="NORMAL|NO CHANGE IN APPETITE|NO ABDOMINAL PAIN|NO HEMATEMESIS|CHANGE IN APPETITE|NO N/V/D|ABDOMINAL PAIN|HEMATEMESIS|NAUSEA|VOMITING|DIARRHEA"][text name="ros_gi" default=" "]
-GU: [checkbox name="ros_gu_check" value="NORMAL|NO URINARY FREQUENCY|NO URINARY URGENCY|NO DYSURIA|NO HEMATURIA|NO LEAKAGE OF URINE|URINARY FREQUENCY|URINARY URGENCY|DYSURIA|HEMATURIA|LEAKAGE OF URINE"][text name="ros_gu" default=" "]
-MSK: [checkbox name="ros_msk_check" value="NORMAL|NO BACK PAIN|NO JOINT PAIN|NO MUSCLE ACHES|NO GENERALIZED MUSCLE PAIN|NO NECK PAIN|BACK PAIN|JOINT PAIN|MUSCLE ACHES|GENERALIZED MUSCLE PAIN|NECK PAIN"][text name="ros_msk" default=" "]
-SKIN: [checkbox name="ros_skin_check" value="NORMAL|NO RASH|NO BRUISING|NO LESIONS|NO ITCHING|RASH|BRUISING|LESIONS|ITCHING"][text name="ros_skin" default=" "]
-NEURO: [checkbox name="ros_neuro_check" value="NORMAL|NO HEADACHE|NO DIZZINESS|NO SYNCOPE|NO LOSS OF CONSCIOUSNESS|HEADACHE|DIZZINESS|SYNCOPE|LOSS OF CONSCIOUSNESS"][text name="ros_neuro" default=" "]
-PSYCH: [checkbox name="ros_psych_check" value="NORMAL|DENIES SUICIDAL/HOMICIDAL IDEATIONS|NO HALLUCINATIONS|NO DEPRESSION|NO ANXIETY|SUICIDA/HOMICIDAL IDEATIONS|HALLUCINATIONS|DEPRESSED|ANXIOUS"][text name="ros_psych" default=" "]
-ENDOCRINE: [checkbox name="ros_endo_check" value="NORMAL|NO HEAT/COLD INTOLERANCE|NO EXCESSIVE THIRST|NO POLYURIA|HEAT INTOLERANCE|COLD INTOLERANCE|EXCESSIVE THIRST|POLYURIA"][text name="ros_endo" default=" "]
-HEMATOLOGIC: [checkbox name="ros_heme_check" value="NORMAL|NO EXCESSIVE BRUISING|NO EXCESSIVE BLEEDING|EXCESSIVE BRUISING|EXCESSIVE BLEEDING"][text name="ros_heme" default=" "]
PHYSICAL EXAM

-EKG FINDINGS: [checkbox name="EKG" value="SINUS RHYTHM|SINUS BRADYCARDIA|SINUS TACHYCARDIA|SINUS ARRHYTHMIA|WANDERING ATRIAL PACEMAKER|MULTIFOCAL ATRIAL TACHYCARDIA|AFIB|AFIB W/RVR|SUPRAVENTRICULAR TACHYCARDIA|ATRIAL FLUTTER|JUNCTIONAL RHYTHM|FIRST DEGREE AV BLOCK|SECOND DEGREE TYPE 1|SECOND DEGREE TYPE 2|3RD DEGREE BLOCK|IVR|ACCELERATED IVR|VTach|VFIB|ASYSTOLE|PEA|TORSADES|W/PVC'S|W/PAC'S|W/PJC'S"][text name="ros_heme" default=" "]
-GENERAL: [checkbox name="pe_general_check" value="WELL DEVELOPED/WELL NOURISHED|WELL APPEARING|IN NO ACUTE DISTRESS|MALNOURISHED|IN ACUTE DISTRESS|OBESE"][text name="pe_general" default=" "]
-HEENT: [checkbox name="pe_heent_check" value="NORMOCEPHALIC|ATRAUMATIC|PERRLA|WHITE SCLERA|CONJUNCTIVA PINK/RED|EARS PATENT|NO BLEEDING|BLEEDING|POSITIVE HALO TEST|NEGATIVE HALO TEST|DRY MUCOUS MEMBRANES|EXTRA SALIVATION|NORMAL MUCOUS|NORMAL PHARYNX|NO TRAUMA TO MOUTH|TRAUMA TO FACE|TRAUMA TO MOUTH"][text name="pe_heent" default=" "]
-CARDIOVASCULAR: [checkbox name="pe_cardio_check" value="REGULAR RATE AND RHYTHM|NO ST ELEVATION|NO JUGULAR VEIN DISTENTION|NO EDEMA|PERIPHERAL PULSES INTACT|NO CYANOSIS|IRREGULAR RATE|IRREGULAR RHYTHM|ST ELEVATION PRESENT|JVD PRESENT|EDEMA PRESENT|NO PERIPHERAL PULSES|CYANOSIS PRESENT|BLEEDING"][text name="pe_cardio" default=" "]
-RESPIRATORY: [checkbox name="pe_resp_check" value="CLEAR TO AUSCULTATION BILATERALLY|NO RALES, RHONCHI, WHEEZES|NO RETRACTIONS|NO ACCESSORY MUSCLE USE|NO STRIDOR|WHEEZING|UPPER RESPIRATORY CONGESTION"][text name="pe_resp" default=" "]
-GI:[checkbox name="pe_gi_check" value="atraumatic.|BS PRESENT IN ALL 4 QUADRANTS|ABDOMEN SOFT/NON-TENDER TO PALPATION|NON-DISTENDED|NO RIGIDITY|NO GUARDING|NO MASSES|NORMAL|TRAUMA PRESENT|TENDER ABDOMEN|RIGID ABDOMEN|DISTENDED ABDOMEN|GUARDING PRESENT|MASSES PRESENT"][text name="pe_gi" default=" "]
-MSK: [checkbox name="pe_msk_check" value="NORMAL RANGE OF MOTION|NO PAIN ON PALPATION|STRENGTH 5/5 IN ALL EXTREMITIES|ABNORMAL RANGE OF MOTION|PAIN ON PALPATION|STRENGTH NOT PRESENT IN ALL EXTREMITIES"][text name="pe_msk" default=" "]
-SKIN: [checkbox name="pe_skin_check" value="NO RASH|NO LESION|NO DISCOLORATION|PINK|WARM|DRY|PALE|COOL|CYANOTIC|FLUSHED|CLAMMY|HOT"][text name="pe_skin" default=" "]
-NEURO: [checkbox name="pe_neuro_check" value="GROSSLY ORIENTED X 4|GAIT NORMAL|SENSATION INTACT|NORMAL REFLEXES|SMILE NORMAL|SPEECH NOT SLURRED|NEURO NOT GROSSLY INTACT|GAIT ABNORMAL|SENSATION ABSENT|NO REFLEXES|SMILE NOT SYMMETRICAL|SLURRED SPEECH"][text name="pe_neuro" default=" "]
-PSYCH: [checkbox name="pe_psych_check" value="PLEASANT, CALM, AND COOPERATIVE|JUDGEMENT AND INSIGHT INTACT|HAS A PLAN MADE|UNDERSTANDS TREATMENT|THOUGHT PROCESS NORMAL|NORMAL AFFECT|UNPLEASANT|NOT CALM|UNCOOPERATIVE|DOES NOT HAVE A PLAN|DOES NOT UNDERSTAND TREATMENT"][text name="pe_psych" default=" "]
-HEMATOLOGIC: [checkbox name="pe_heme_check" value="NO TENDERNESS OR MASSES PALPATED|NO BRUISES|NO BLEEDING|TENDERNESS|BRUISING|BLEEDING"][text name="pe_heme" default=" "]
TREATMENT:[textarea name="Treatment" default=" "]

HOSPITAL ACTIVATIONS: [checkbox name="pe_act_check" value="CONTACTED FOR STROKE|CONTACTED FOR TRAUMA|THROMBOLYTIC CHECKLIST COMPLETED|STEMI|HISTORIAN   AND    CONTACT    NUMBER    GATHERED"]
TRANSPORT: [checkbox name="pe_trans_check" value="SECURED TO STRETCHER|3 STRAPS|LOADED FOR TRANSPORT|EMERGENCY|NON EMERGENCY|EMERGENCY DOWNGRADED TO NON EMERGENCY|NON EMERGENCY UPGRADED TO EMERGENCY|PATIENT REFUSED TRANSPORT|AMA|PATIENT TREATED AND RELEASED|NO TRANSPORT|LIFT ASSIST ONLY|TRANSPORTED TO RECEIVING HOSPITAL"]

REPORT:  
[checkbox name="Report" value="VERBAL REPORT TO NURSE|PATIENT BELONGINGS LEFT WITH NURSE|IMPROVEMENT IN PATIENT CONDITION|DECLINE IN PATIENT CONDITION|NO CHANGE IN PATIENT CONDITION"]
[text name="pe_rep" default=" "]
has requested medical transport of this patient, and has agreed to receive this patient in transfer. Patient is being transferred to for a higher level of care and services not available at the sending facility. is the closest appropriate facility with both the services this patient needs, as well as an available bed.

HPI: -year-old with a history of who presented to via . Per report patient .

ER Course: Pt was seen and evaluated by hospital staff and found to have . Treatments as listed below and in hospital medical record. Pt being transferred for higher level of care/services not available at sending (as noted above in HPI).

Treatments PTA: .

Physical Exam
VS reviewed and as documented. RN notes reviewed.
Gen:
HEENT:
Neck:
CV:
Resp:
Abd:
MSK:
GU:
Rectal:
Neuro:
Skin:

Access:
CVL:
PIV:
Arterial:

Labs: Reviewed. Remarkable for . Please see hospital documentation for full details
EKG:
Imaging:

MDM: All labs, history, and imaging reports reviewed independently. History discussed with patient care team. Upon review of the patient’s chief complaint, history of present complaint, past medical history, physical exam findings, diagnostic imaging results, and lab results, it is determined that the patient is experiencing
Appropriate PPE precautions taken. Pt attached to cardiac monitor.




Transport Course: INITIAL ABC's:
-AIRWAY:
-Breathing:
-CIRCULATION: REVIEW OF SYSTEMS:
-CONSTITUTIONAL:
-HEENT:
-CARDIOVASCULAR:
-RESPIRATORY:
-GI:
-GU:
-MSK:
-SKIN:
-NEURO:
-PSYCH:
-ENDOCRINE:
-HEMATOLOGIC:
PHYSICAL EXAM

-EKG FINDINGS:
-GENERAL:
-HEENT:
-CARDIOVASCULAR:
-RESPIRATORY:
-GI:
-MSK:
-SKIN:
-NEURO:
-PSYCH:
-HEMATOLOGIC:
TREATMENT:


HOSPITAL ACTIVATIONS:
TRANSPORT:

REPORT:


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.32, 92 form elements, 244 boilerplate words, 62 text boxes, 1 text areas, 29 checkboxes, 347 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: