Lowercase 911

arrived: [checkbox name="arrived" value="on scene w/o incident and no change in response mode|canceled en-route|canceled on-scene"] applied ppe of [checkbox name="ppe" value="gloves|gown|goggles/face shield|surgical mask|n95|respirator"]

patient appearance: [checkbox name="pe_general_check" value="well developed, well nourished, and well appearing|in no acute distress|malnourished|in acute distress|obese|appears ill|appears frail|obvious signs of death"][text name="pe_general" size = 55 default=" "]

initial abc's:
-airway: [checkbox name="airway" value="maintained by patient|no concerns of compromise|airway patent|no airway obstructions|compromised|airway positioned to open|airway not patent|obstructions to airway|requires airway adjunct|requires advanced airway|requires artificial ventilation"][text name="airway" size = 55 default=" "]

-breathing: [checkbox name="breathing" value="breathing spontaneously|breathing regular|adequate respirations|appropriate tidal volume|not spontaneously breathing|irregular respirations|inadequate respirations|inadequate tidal volume|rapid|slow|deep|shallow|apneic"][text name="breathing" size = 55 default=" "]

-circulation: [checkbox name="circulation" value="no concerns of circulation|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|pulses weak|pulses bounding"][text name="ros_constitutional" size = 55 default=" "]

-level of consciousness: [checkbox name="loc" value="alert|oriented|person|place|time |event|disoriented|arousable by verbal stimuli|arousable by painful stimuli|baseline for pt|unresponsive|unconscious|unresponsive, unconscious, pulseless, and apneic"][text name="consciousness" size = 55 default=" "]

-psych: [checkbox name="ros_psych_check" value="pleasant, calm, and cooperative, judgement and insight intact, understands treatment, thought process is logical/linear and age appropriate with normal affect|has a plan made|unpleasant|not calm|uncooperative|does not have a plan|does not understand treatment|impaired attention/concentration|judgement and insight not intact|mood instability|denies - suicidal ideations, homicidal ideations, auditory hallucinations, visual hallucinations, depression, or mood changes|affirms -|suicidal ideations|homicidal ideations|auditory hallucinations|mood changes|visual hallucinations|distracted|unhappy|agitated|apathy|anxious|worries|dissociative|upset|tearful|fearfulness|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="ros_psych" default=" "]

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

hx of cc: [text name="cc" size = 55 default=" "]
additional signs/symptoms reported: [textarea name="s" size = 55 default=" "]
events surrounding condition: [textarea name="e" size = 55 default=" "]
other pertinent hx: [textarea name="hpi" default=" "]

review of systems:

-constitutional: [checkbox name="ros_constitutional_check" value="denies -|fever|chills|weakness|fatigue|weight loss|age related muscular atrophy|senescence|frailty|affirms - |fever|chills|weakness|fatigue|weight loss|frailty|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="ros_constitutional" default=" "]

-heet: [checkbox name="ros_heent_check" value="normocephalic, atraumatic, white sclera, conjunctiva pink/red, ears patent|eyes perrla|normal mucous|no bleeding|no trauma to face or mouth|eyes not perrla|pupils dilated|pupils constricted|bleeding|dry mucous membranes|extra salivation|trauma to face|trauma to mouth|glasses|contact lens|denies - facial pain, vision changes, eye irritation, ear pain, nasal congestion|affirms -|vision changes|eye irritation|ear pain|nasal congestion|facial pain|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="ros_heent" default=" "]

-neck: [checkbox name="ros_neck_check" value="supple neck|no neck swelling/lumps|bleeding|trauma to neck|neck swelling/lumps|jugular vein distension|tracheal deviation - left|tracheal deviation - right|denies - sore throat, neck pain,throat congestion or cough|affirms -|sore throat|throat congestion|cough|neck pain|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="ros_neck" default=" "]

-chest: [checkbox name="pe_chest_check" value="bilateral equal rise and fall|concave chest - normal|bleeding|atraumatic|no tenderness|tenderness|barrel chest|clear to auscultation bilaterally upper/middle/lower lobes|no rales, rhonchi, wheezes, stridor, pleural rub, retractions, or accessory muscle use|wheezing|rales|rhonchi
|stridor|pleural rub|retractions|upper respiratory congestion|accessory muscle use|right upper lobe|right middle lobe|right lower lobe|left upper lobe|left lower lobe|bilaterally|no flail segment|unequal chest rise and fall|flail segment|denies - shortness of breath, hemoptysis, orthopnea, dyspnea on exertion, dyspnea, chest pain or discomfort, palpitations, or swelling of extremities|affirms - |chest pain/discomfort|palpitations|swelling of extremities|shortness of breath|dyspnea on exertion|chest pain/discomfort|palpitations|hemoptysis|orthopnea|dyspnea|apneic|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="pe_chest" default=" "]

-gi: [checkbox name="ros_gi_check" value="atraumatic, non-distended or rigid, no guarding|bowel sounds present in all 4 quadrants|abdomen soft/non-tender to palpation, no masses, no rebound tenderness|rebound tenderness|trauma present|tender abdomen|rigid abdomen|distended abdomen|guarding present|masses present|generalized|left lower quadrant|left upper quadrant|right lower quadrant|right upper quadrant|denies - n/v/d, constipation, change in appetite, dysphagia, abdominal pain, melena, hematochezia or hematemesis|affirms -|change in appetite|abdominal pain|hematemesis|melena|hematochezia|dysphagia| nausea|vomiting|diarrhea|constipation|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="ros_gi" default=" "]

-gu: [checkbox name="ros_gu_check" value="stable gait|no tenderness|fecal incontinence|denies - leakage of urine, dysuria, hematuria, oliguria, increased urinary frequency or urgency|denies sexual dysfunction|denies fecal incontinence|affirms -|sexual dysfunction|abnormal genitalia discharge|increased urinary frequency|foley placed|increased urinary urgency|dysuria|oliguria|hematuria|leakage of urine|pelvic tenderness|unstable gait|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="ros_gu" default=" "]

-msk: [checkbox name="ros_msk_check" value="normal range of motion|without pain on palpation|no crepitus|no obvious deformity|strength age appropriate|abnormal range of motion|pain on palpation|strength not present|crepitus|contractures present|asthenia|obvious deformity|in all extremities|left upper extremity|right upper extremity|left lower extremity|right lower extremity|denies - neck pain, generalized joint pain, generalized muscle aches/pain/cramps/weakness|affirms -|neck pain|generalized joint pain|generalized muscle aches|generalized muscle pain|generalized muscle cramps|generalized muscle weakness|contractures present|asthenia|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="ros_msk" default=" "]

-back: [checkbox name="ros_back_check" value="unremarkable back inspection|abnormal back inspection|full range of motion|abnormal range of motion|denies - back pain, lower back pain/dorsalgia/lumbago|affirms -|upper back pain|mid back pain|lower back pain/dorsalgia/lumbago|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="ros_back" default=" "]

-skin: [checkbox name="ros_skin_check" value="no rashes, skin tears, swelling, lesions, or discoloration|pink, warm, and dry, w/ good turgor|pink|dry|pale|cool|cyanotic|flushed|clammy|hot|warm|diaphoretic|lividity|mottling|jaundiced|skin tear|swelling|poor skin turgor|excessively dry skin|denies - skin pain, numbness, tingling, discoloration, swelling, rash, bruising, lesions, skin breaks, sensitivity or itching|affirms -|rash|bruising|lesions|skin pain|numbness|tingling|discoloration|sensitivity|swelling|skin breaks|itching|unable to assess to due to uncooperative state|unable to assess accurately due to altered mental state"][text name="ros_skin" default=" "]

-neuro: [checkbox name="ros_neuro_check" value="grossly oriented x 4, gait steady & balanced, sensation intact with normal reflexes, smile symmetrical, and speech not slurred|neuro not grossly intact|aphagia|aphasia|deceberate posturing|decorticate posturing|seizure activity|strength asymmetrical|gait abnormal|sensation absent|no reflexes|smile asymmetrical|hemiplegia|hemiparesis|slurred speech|obtunded|denies - headache, dizziness, syncope, numbness/tingling, seizures or otherwise loss of consciousness|denies focal deficits|affirms -|focal deficits|incoordination|memory deficits|headache|dizziness|obtunded|syncope|numbness/tingling|loss of consciousness|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess to due to uncooperative state"][text name="ros_neuro" default=" "]

treatment: [checkbox name="treatment" value="primary and secondary als assessment|primary and secondary bls assessment|continuous cardiac monitoring|12-lead ekg|active external cooling of subject|active external warming of subject|cervical collar placed|cervical spine immobilization|etco2 monitoring|airway suction technique w/ yankauer|bag valve mask ventilation|cardiopulmonary resuscitation|obtained orthostatic vital signs|vagal stimulation|wound care|mechanically assisted chest compression|intraosseous cannulation flushed w/ ns 0.9% blood return noted|vascular access flushed w/ ns 0.9% blood return noted secured w/ tegaderm/tape"] [textarea name="rxt" default=" "]

hospital activations: [checkbox name="pe_act_check" value="contacted for stroke|contacted for trauma|thrombolytic checklist completed|historian information and contact number gathered|no alerts activated"][text name="pe_act" default=" "]

transport from scene: [checkbox name="pe_trans_check" value="emergency/lights and siren|non-emergency/no lights and siren|emergency downgraded to non-emergency/no lights and siren|non-emergency upgraded to emergency/lights and siren|lift assist only|pt refused ems evaluation & transport|patient refused evaluation|pt refused transport|patient treated and released|ama|per protocol|no transport required|no treatment required|no patient contact|pt pulseless, apneic on scene w/ resuscitation|pt pulseless, apneic on scene w/o resuscitation|w/ transport|w/o transport|rosc obtained|protocol requirements met, termination of cpr|obvious signs of death, considered futile|er physician order for termination|transferred care to another ems unit - ground|transferred care to another ems unit - air|report called to receiving facility during transport"][text name="pe_trans" default=" "]

mobility on scene: [checkbox name="pe_mobil1_check" value="pt able to ambulate to stretcher|pt moved to stretcher via draw-sheet method|pt placed on stretcher using lift & carry techniques|pt placed on stretcher using spineboard|w/o assistance|w/ assistance|w/o incident or pain expression or discomfort|w/ pain/discomfort expressed|secured patient to stretcher with 4 straps and 2 rails upright|supine position|low fowler's position|semi-fowler's position|fowler's position|full fowler's/sitting position|loaded into ambulance for transport w/o incident"][text name="pe_mobil1" default=" "]

mobility at destination: [checkbox name="pe_dest_check" value="pt able to ambulate from stretcher to hospital bed|pt moved from stretcher to hospital bed via draw-sheet|pt moved from stretcher to hospital bed via spineboard|w/o assistance|w/ assistance|w/o incident|improvement in patient condition|decline in patient condition|no change in patient condition|patient belongings left with nurse|verbal report communicated to nurse"][text name="pe_dest" default=" "]

nurse receiving patient: [text name="nurse" size = 55 default=" "]

signatures: [checkbox name="signature" value="obtained from patient|obtained from guardian/poa|obtained from responsible party|not obtained from patient|unable to sign|law enforcement signed as|nurse signed as|ems crew signed as| representative|witness|no representative available"][text name="pe_signature" default=" "]

[checkbox name="ama" value="in spite of multiple attempts by myself and my partner to convince the patient(and/or responsible party) to be transported to hospital for evaluation and treatment, we have unfortunately been unsuccessful. however, the patient(and/or responsible party) has the capacity to give, receive, and withhold information. the patient(and/or responsible party) verbalizes understanding of their condition and symptoms and that refusing care could pose significant risk to their own life(and/or the patient's life). the patient(and/or responsible party) has verbalized to me that they understand our specific treatment plan which includes transport to hospital, and unfortunately does not agree with us and understands without this treatment may cause worsening of condition or death. the patient(and/or responsible party) understands they are free to call 911 if condition worsens and they feel they wish to be transported to emergency department for further evaluation and treatment."]

report writer: [text name="writer" size = 55 default=" "]
arrived: applied ppe of

patient appearance:

initial abc's:



-level of consciousness:



hx of cc:
additional signs/symptoms reported:

events surrounding condition:

other pertinent hx:

review of systems:












hospital activations:

transport from scene:

mobility on scene:

mobility at destination:

nurse receiving patient:


report writer:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.46, 54 form elements, 61 boilerplate words, 25 text boxes, 4 text areas, 25 checkboxes, 483 total clicks
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