HEMS Scene Template

Chief Complaint: [text name="cc" default="" size="55"]

Dispatch Info: Requested to [text name="referringblank" default="" size="55"] in rural [text name="referringcity" default="" size="55"] for an unscheduled scene request.

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"] found [text name="ptfound" default="" size="55"].  Per report patient [text name="eventsleadingup" default="" size="55"].


Treatments PTA: [text name="txpta" default="No treatments performed PTA" size="55"].


PMH: [text name="pmh" default="" size="55"].
PSH: [text name="psh" default="" size="55"].

Meds: [text name="meds" default="" size="55"].
Allergies: [text name="allergies" default="" size="55"].

ROS: A 10 pt review of systems was negative and/or unobtainable unless otherwise indicated in the HPI.

Physical Exam
Gen: [text name="gen" default="Resting, 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: [text name="centralvenousaccess" default="Not present" size="55"]


Labs: [text name="labvalues" default="Not present/available" size="55"] 
EKG: [text name="ecg" default="Not present/available" size="55"]
Imaging: [text name="imaging" default="Not present/available" size="55"] 

MDM: All available labs, history, and imaging reports reviewed independently. 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 monitor. Transfer to unit uneventful.
Pt is being transported to [text name="destination" default="" size="55"] as this is the closest most appropriate facility with both the services the patient requires, as well as an available bed. 

Transport Course: [text name="transportcourse" default="Interventions/actions performed during the transport..." size="55"]

Upon arrival at receiving facility, pt transferred to hospital bed uneventfully. Pt care and report given to RN and all questions answered prior to departure from facility. Pt belongings and transport paperwork left with staff.

Assessment/Impression:
[text name="impression1" default="" size="55"]
[text name="impression2" default="" size="55"]
[text name="impression3" default="" size="55"]
[text name="impression4" default="" size="55"]
[text name="impression5" default="" size="55"]
[text name="impression6" default="" size="55"]
[text name="impression7" default="" size="55"]
[text name="impression8" default="" size="55"]
[text name="impression9" default="" size="55"]
[text name="impression10" default="" size="55"]

Intake: [text name="intake" default="" size="55"]mL. 
Output: [text name="output" default="" size="55"]mL. 

Cabin Temp Initial: [text name="cabintemp1" default="" size="55"]F cabin HVAC applied
Cabin Temp Ending: [text name="cabintemp2" default="" size="55"]F


As a result of the dynamic pre-hospital environment in which limited resources are available the times noted in this patient care report may be approximated. 
Chief Complaint:

Dispatch Info: Requested to in rural for an unscheduled scene request.

HPI: -year-old with a history of found . Per report patient .


Treatments PTA: .


PMH: .
PSH: .

Meds: .
Allergies: .

ROS: A 10 pt review of systems was negative and/or unobtainable unless otherwise indicated in the HPI.

Physical Exam
Gen:
HEENT:
Neck:
CV:
Resp:
Abd:
MSK:
GU:
Rectal:
Neuro:
Skin:

Access:


Labs:
EKG:
Imaging:

MDM: All available labs, history, and imaging reports reviewed independently. 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 monitor. Transfer to unit uneventful.
Pt is being transported to as this is the closest most appropriate facility with both the services the patient requires, as well as an available bed.

Transport Course:

Upon arrival at receiving facility, pt transferred to hospital bed uneventfully. Pt care and report given to RN and all questions answered prior to departure from facility. Pt belongings and transport paperwork left with staff.

Assessment/Impression:











Intake: mL.
Output: mL.

Cabin Temp Initial: F cabin HVAC applied
Cabin Temp Ending: F


As a result of the dynamic pre-hospital environment in which limited resources are available the times noted in this patient care report may be approximated.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 45 form elements, 222 boilerplate words, 45 text boxes, 45 total clicks
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