LCEMS CHART

Incident/Dispatch:[textarea name="incident" default="Unit 602 was dispatched to  "]
Upon Arrival: [textarea name="ptinfo" default="Upon ems arrival patient was found"]
Past History:[checklist name="Past History" value="Hypertension|Hypotension|Hypothyroidism|Hyperthyroidism|Diabetes|Stroke/Cva|Psych History|cardiac arrhythmia|Copd|Asthma|Chf|"]Other[text name="variable_1" default=""]
Allergies Noted- [checkbox name="variable_1" value="NKA|Other"][text name="variable_1" default=""]
Pain Level[select name="variable_1" value="|Its a Great day| 0|1|2|3|4|5|6|7|8|9|10|Bear Just ate my leg and its gone"]

Assessment:
GENERAL: [textarea name="appearance" default=" Interacting with EMS appropriately; well appearing; not acutely distressed. "]
CNS: [textarea name="CNS" default=" Speech is not slurred; CMS grossly intact in all 4 extremities; gait is steady. "]
PSYCH: [textarea name="psych" default=" No reported recent or active suicidality or homicidal ideations. No reported recent or active visual/auditory disturbances. "]
CARDIOVASCULAR: [textarea name="cardiovascular" default=" No immediate concerns. Equal radial pulses bilaterally. "]
PULMONARY: [textarea name="PULM" default=" No initial immediate concerns. 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. "]

Physical Exam:
HEAD: [textarea name="head" default=" No noted pain or trauma. Pupils equally round/reactive at 4mm in size. No facial droop. "]
NECK: [textarea name="NECK" default=" No noted pain or trauma. No JVD. No midline pain. "]
CHEST: [textarea name="chest" default=" No noted pain or trauma. Equal rise and fall. Breath sounds CTA bilaterally. "]
BACK: [textarea name="back" default=" No noted pain or trauma. "]
ABDOMEN: [textarea name="abd" default=" No noted pain or trauma. Soft, flat, non-tender. "]
PELVIS: [textarea name="pelvis" default=" No noted pain or trauma. Stable. "]
EXTREMITIES: [textarea name="extremities" default=" No noted pain or trauma. No clubbing, cyanosis or edema. "]
SKIN: [textarea name="skin" default=" Normal tone, warm, dry. "]
EKG: [textarea name="ekg" default=" "]

TREATMENT: 
[textarea name="variable_1" default=""Patient was placed on the stretcher then secured with straps x 5 and rails up x2. They were then connected to the cardaic monitor and vitals were taken. ""]

TRANSPORT: 
[textarea name="TPU" default=" Transport non-emergent to HOSPITAL with pre-arrival notification made enroute. During transport patient remains stable."]

HOSPITAL ARRIVAL:
[textarea name="hosp" default=" Upon arrival at ED handoff given to nurse  R.N. at bedside. Nurse signs PCR. Patient signs PCR. "]

No further care.
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[checkbox name="Student" value="*Some assessments and procedures were performed by paramedic student who was under my direct supervision as the attending paramedic, and consistent with student's scope of practice.*"]
[checkbox name="Disclaimer" value="*Please note that this dictation was completed with computer voice recognition software. Oftentimes unanticipated grammatical, syntax, homophones, and other interpretive errors are inadvertently transcribed by the computer software. Please disregard these errors. Please excuse any errors that have escaped final proofreading.*"]