IFT ALS Transport

NARRATIVE:[comment memo="DISPATCH info"]
Medic Unit [select name="unit" value="|1101|1102|1103|1104|1201|1202|1203|1204|1205"] was dispatched to [select name="origin" value="|SNVMC|SENTARA LAKE RIDGE|FAUQUIER|KAISER CATON HILL|UVA HAYMARKET|UVA PRINCE WILLIAM|VHC|INOVA HEALTHPLEX|OTHER"] for [select name="trans_lvl" value="an EMERGENT, non-critical transport|SCHEDULED transport|a CRITICAL response transport"] to [select name="dest" value="|VHC|INOVA FAIRFAX|SNVMC|KAISER CATON HILL|UVA HAYMARKET|UVA PRINCE WILLIAM|the PATIENT'S RESIDENCE|SKILLED NURSING FACILITY|ASSISTED-LIVING FACILITY|OTHER"] [select name="admit" value="for treatments/specialty care not provided/ available at current facility.|to be admitted to the main hospital for in-patient care.|for emergent surgery.|for surgery not available at current facility.|for treatments not provided/ available at current facility.|for long-term care and rehabilitation not provided at current facility.|after being discharged from the facility.|after discharged into hospice care."]
[comment memo="ON SCENE"]
ON-SCENE AT ORIGIN:
Upon arrival to the facility the crew met with the patient, who was [select name="where" value="in the room, alone|in the room, with family|in the room with a friend"], [select name="status" value="awake|asleep|sedated"] and [select name="doing" value="lying in the bed at semi-fowlers.|lying in the bed at fowlers.|lying in the bed at supine.|sitting in room's chair.|OTHER"]
[comment memo="REPORT"]
REPORT FROM RN:
Patient is a [text name="age" default="" size="5"]-year-old [select name="sex" value="|Female|Male"], who [select name="trans" value="was evaluated in the ED for |was admitted to the facility for "][textarea name="CC" default=""]. Patient was diagnosed with: [text name="dx_code" default="" size="30"].
Pertinent Medical History: [text name="medhx" default="" size="50"].
[comment memo="IMAGING"][checkbox name="variable_1" value="Facility did not preform any imaging.|Facility preformed:"][checkbox name="imgtype" value="ECG,|    MRI,| CT,| X-RAY,|ULTRASOUND"][select name="results" value="|results SHOWED |results CONFIRMED |results RULED OUT "][select name="testdx" value="|a STROKE|a STEMI|an N-STEMI Ischemia|a CVA|a CEREBRAL HEMORRHAGE|a SUBDURAL HEMATOMA|a MASS|a FRACTURE"][text name="other_symp" default=""]. 
[checkbox name="NIHVAL" value="NIH Score: "][text name="NIHSCORE" size="20" default=""] 
[checkbox name="GCS" value="GCS Score: "][text name="GCSSCORE" size="5" default=""] 
[checkbox name="LABS" value="PERTINENT LABS: "][textarea name="labs" default=""]
Face Sheet and Patient Care Summary was reviewed of the facility's assessments, treatments, imaging, labs, and other pertinent notes. Pertinent Records were scanned and placed in PCR and transported with the patient to destination.

INTERVENTIONS IN PLACE, PRIOR TO ARRIVAL:
IV ACCESS: [text name="IVACC" size="5" default=""]g, Located in the: [select name="LOCIV" value="|RIGHT|LEFT"] [text name="IVP" size="5" default="AC"], IV was placed by [select name="PLACEDBY" value="RN at origin facility, prior to arrival|MEDIC on scene"]. IV site was assessed for signs of infiltration; site was clean, without redness, and flushed smoothly with NS.
[checkbox name="MEDS" value="MEDICATIONS: "][textarea name="medadmin" default=""]
[checkbox name="tx_mon_opt2" value="Oxygen Administration: "][text name="LPM" size="20" default=""]
[checkbox name="HIGHFLOW" value="HIGHFLOW: FiO2: XX, O2: XX"]
[checkbox name="FOLEY" value="FOLEY"]
[checkbox name="TRACH" value="TRACHEOSTOMY: In place on arrival. Tube in place with no signs or symptoms of inflammation, infection, irritation, trauma, or blockages. Tube is secured in place at this time. Patient is able to adequately and spontaneously ventilate at this time."]
[checkbox name="WOUNDVAC" value="WOUND VAC: Site appears to have good seal, no pressure alarms at this time. No tears, seeping, and no new agitation or infection noted according to sending staff."]
[checkbox name="CHESTTUBE" value="CHEST TUBE: 32 French placed in 5th intercostal at midaxillary line on the patient's LEFT / RIGHT side. Tube is sutured in place and secure. Good drainage into XXX with a good seal. Current volume of XXX with blood, XXX in color."]
[checkbox name="Intubation" value="INTUBATION: Occured at: , By: , ETT SIZE: XX, CM AT TEETH: XX, ETC02: XX."]
[checkbox name="ventsettings" value="VENT SETTINGS (AT ORIGIN) FiO2: XXX /PEEP:XXX /RR:XXX /TV:XXX, Good wave form noted at this time.(ON TRANS. VENT) FiO2: XXX /PEEP:XXX /RR:XXX /TV:XXX, Good wave form noted at this time."]
[comment memo="ECG"]
[select name="ECG" value="ECG MONITORING DURING TRANSPORT:|ECG MONITORING: N/A.|ECG MONITORING: Discontinued, Not nessesary for transport."] [checkbox name="ECG1" value="12-Lead ECG. Monitoring was continued during transport and results are as documented.|4-Lead ECG. Monitoring was continued during transport and results are as documented."]
After transfer of care was completed; Medic then met with the patient and preformed an assessment and was documented in the PCR; with key assessment points noted below.
[comment memo="ASSESSMENT"]
KEY ASSESSMENT FINDINGS: 
AOx[text name="AO" default=""]. PAIN [text name="PAIN" default="/10"]. [checkbox name="CP_SSS" value="CP-SSS Score: "][text name="CPSSSCORE" size="5" default=""] 
Significant findings are noted to be:[textarea name="assmentfindings" default=""]
[checkbox name="standard" value="Patient was found to be calm and in no acute distress. ABC’s were intact. Patient spoke with appropriate language and in full sentences. Speech was clear without dysphasia.|Patient was found to speeking in full and complete sentences. Speech was clear, however slightly laboured after one to two sentences.|Patient spoke in a hoarse voice, sentences were confused/broken. Speech was laboured after one to two word/sentences.|Patient speech was low and with slight changes in breathing pattern after two - three sentences, however it was unlabored and appropriate. She spoke in complete, unbroken sentences and without dysphasia.|ABC’s were intact. However the patient appered to be in distress due to pain / respiratory condition. Patient also appered to have AMS and was slow to respond when asked questions."]
[comment memo="MOVING    THE    PT"]
Appropriate PPE precautions were taken. Patient was moved to the stretcher by [select name="ptmove" value="two-man drawsheet.|assisted stand-and-pivot.|unassisted ambulation."] Patient was secured with seatbelts, attached to the monitor and initial vitals taken and are as documented. Patient was moved to the ambulance without incident. Once in an ambulance, patient vitals were continuously monitored per protocol and are as documented. 
[comment memo="DURING    TRANS"]
DURING TRANSPORT:
[checkbox name="TREATMENTSTRANS" value="Significant changes in condition were:"] [text name="TREATMENTSINTRAN" size="50" default=""]
Transportation en route to receiving facility was [checkbox name="Transport" value="without delay or incident.|without delay or incident. While    transporting, patient received interventions of |UPGRADED to CRITICAL status due to significant changes in patient condition. Interventions performed during the transport are as document."]
[comment memo="AT DESTINATION"]
ON-SCENE AT DESTINATION:
Upon arrival, the crew moved the patient by stretcher into [select name="howptmovedest" value="the receiving facility.|patient's home."] Patient was moved from stretcher to the bed by [select name="ptmovedest" value="two-man drawsheet|assisted stand-and-pivot|unassisted ambulation"], without incident. Patient report and paperwork was given to the attending RN who signed for transfer of care. Patient was left in the bed at semi fowlers, in the care of the RN and staff, with belongings left with patient. 

EOR
NRP Tomecek, C