Luzerne County EMS 911 Narrtive

Date of Run:[date name="ReportDate" default="today"]
Run Number:[text name="RunNumber" default="#"]

Crew Members:
[text name="Crew1" default=""] /EVO
[text name="Crew2" default=""] /Primary Care Provider
[text name="Crew3" default=""] [text name="secondary" default=""]


Disptached: 
[text name="unit" default="Medic 10"] was dispatched by [select name="dispatchedby" value="Luzerne County 911|Trans-Med Disptach"] out to above address in reference to [text name="AGE" default="AGE IN YEARS"] [select name="gender" value="Male|Female"] for [textarea name="disp" default="Call Type"]. Unit responded in an according to the above location. We [select name="scene" value="arrived on-scene without incident.|were cancelled en route.|canceled on scene."]

Complaint:
Patient was complaining of [text name="complaint" default="complaint"]
Patient was found [textarea name="ptfound" default="sitting upright..."]

HX:
[textarea name="Hx_for_complaint" default="Hx surrounding complaint"] 
Patient's medical history, medications, and allergies documented in appropriate section. 

Assessment: 
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=" "]
-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 regular|adequate respirations|appropriate tidal volume|not spontaneously breathing|irregular respirations|inadequate respirations|inadequate tidal volume|breathing spontaneously|rapid|slow|deep|shallow|apneic"][text name="breathing" size = 55 default=" "]
-Circulation: [checkbox name="circulation" value="Normal for patient.|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 not 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|pharmacologically sedated|unresponsive, unconscious, pulseless, and apneic"][text name="consciousness" size = 55 default=" "]
-HEENT: [checkbox name="pe_heent_check" value="Normal for patient.|normocephalic, atraumatic, white sclera, conjunctiva pink/red, ears patent, supple neck, no neck swelling/lumps|eyes perrla|normal mucous|no bleeding|no trauma to face or mouth|eyes not perrla|pupils dilated|pupils constricted|positive halo test|negative halo test|dry mucous membranes|extra salivation|trauma to face|trauma to mouth|bleeding|neck swelling/lumps|glasses|contact lens|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_heent" default=" "]
-Cardiovascular: [checkbox name="pe_cardio_check" value="regular rate and rhythm without st elevation, no jugular vein distention, or edema|peripheral pulses intact, without cyanosis|irregular rate|irregular rhythm|st elevation present|jvd present|edema present|no peripheral pulses|cyanosis present|bleeding|did not assess|unable to assess|unable to assess due accurately to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_cardio" default=" "]
-Respiratory: [checkbox name="pe_resp_check" value="clear to auscultation bilaterally upper/middle/lower lobes, no rales, rhonchi, wheezes, stridor, pleural rub, retractions, or accessory muscle use|no respiratory distress|bilateral equal rise and fall|barrel chest|tachypnea|bradypnea|no flail segment|unequal chest rise and fall|flail segment|increased work of breathing|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|artificial ventilations|did not assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_resp" default=" "]
-ABDOMEN: [checkbox name="pe_gi_check" value="Normal for patient.|atraumatic, bowel sounds present in all 4 quadrants, abdomen soft/non-tender to palpation|non-distended or rigid, no guarding, no masses|no rebound tenderness|rebound tenderness|trauma present|tender abdomen|rigid abdomen|distended abdomen|guarding present|masses present|left lower quadrant|left upper quadrant|right lower quadrant|right upper quadrant|did not assess|unable to assess due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess accurately to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_gi" default=" "]
-MSK: [checkbox name="pe_msk_check" value="Normal for patient.|normal range of motion|without pain on palpation|no crepitus|no obvious deformity|strength normal in all extremities|fine motorskills intact|abnormal range of motion|pain on palpation|strength not present|crepitus|obvious deformity|in all extremities|left upper extremity|right upper extremity|left lower extremity|right lower extremity|did not assess|unable to assess|unable to assess due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess accurately to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_msk" default=" "]
-Skin: [checkbox name="pe_skin_check" value="Normal for patient.|no rashes, skin tears, swelling, lesions, or discoloration|pink, warm, and dry, w/ good turgor|pale|cool|cyanotic|flushed|clammy|hot|warm|diaphoretic|lividity|mottling|jaundiced|skin tear|swelling|poor skin turgor|excessively dry skin"][text name="pe_skin" default=" "]
-Neuro: [checkbox name="pe_neuro_check" value="Normal for patient.|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|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_neuro" default=" "]
-Psych: [checkbox name="pe_psych_check" value="Normal for patient.|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|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_psych" default=" "]

ALS Assessmement: 
[checkbox name="alsassemement" value="AlS procedures or interventions were needed as per ALS Protocols|IALS procedures or interventions were needed as per IALS Protocols|ALS assessment was completed and No ALS proceures or interventions were needed, Downgraded to BLS|ALS assessment was done, patient is stable. It was a Police matter and patient was left with PD"][text name="ALSassessment" default=" "]

Treatment:
-Treatment included
[checkbox name="Treatment" value="Vitals BP, SPO2, Pluse, RR, and BGL|Primary and secondary Assessment.|Waveform capnography monitored enroute.|IO access. |QC pads placed. |CPR performed|assisted ventilations with BVM. "]
-IV:[select name="IVsize" value="24g|22g|20g|18g|16g|14g|Not needed| Unsuccessful"] [text name="IVwhere" default="In Left hand"]
-12-Lead:[select name="12Lead" value="Done transmited to hospital|Done transmitted to hospital and signed by medic on location for not life threats|Not Completed"]

-Medcations Givien:
BLS Medication:
[checkbox name="BLSMedcationsgiven" value="No BLS Medications were needed|Oxygen|Asprin|Nitro"]
ALS Medication:
[checkbox name="ALSMedcationsgiven" value="No ALS Medications were needed|Normal saline| Duonebs|Albuterol|Adenosine|Cardizem|dexamethazone|Diphenhydramine|EPI 1:1000|Glucagon|Magnesium|Naloxone|Nitro Paste|Nitro Tabs|Ondanestron|Racemic EPI|Solumedrol|Tetracaine|Toradol|Tylenol|Verapamil|Atropine|Lidocaine|Calcium|D10|D50|BiCarb|Midazolam|Fentanyl|Morphine|Narcan"]
[textarea name="Doseages" default="Routes responce, reason, and dosages"]
[textarea name="othertreatments" default="Other Treatments"]

Decision to Transpot: 
[radio name="transportde" value="Transport|No Transport"]

[conditional field="transportde" condition="(transportde).is('Transport')"]
Loading of Patient:
[checkbox name="loadingpatient" value="Patient was transfer to stretcher by stand and pivot|Patient was sheet lifted|Patient full body lift|Patient was removed by Stairchair| patient was removed by reeves| patient was removed by litter| patient was removed by litter| patient walked with ems assitance|secured patient to stretcher with belts and rails|loaded into ambulance for transport w/o incident|Sat in captains chair and was belted|lift assist only|Treated on scene no transport"] 
The Postion of patient [select name="Postionofpt" value="supine|low fowler's|semi-fowler's|fowler's|full fowler's/sitting"]

Hosptial Destination:
Hospital destination is: [checkbox name="Hosptialrequested" value="Wilkes Barre General|Geisinger Wyoming Valley|Geisinger South|VA Wilkes Barre| LVH Hazleton|CMC|Reginal Scranton|No transport"][text name="otherhospitals" default=" "]
Reason for choice of Hospital:[checkbox name="reasontohosptial" value="Patient Request|Family Request|Clostest Facuitly|Staff Request| PD Request|Patient Emergency Care Facuitly|"][text name="otherhospitals" default=" "]

Pre-Hospital activations:
Pre-hospital alert was done by [select name="prehospreport" value="Phone|Radio|No chance to call|Tried, no answer on hospital side"]
Hospital Alert activated: [checkbox name="pe_act_check" value="Stroke Alert|Level 1 Trauma Activation|Level 2 Trauma Activation|Injury Activation|STEMI Alert| Septic alert|no alerts activated"][text name="pe_act" default=" "]

Transport Condition:
Patients Condition in transport[select name="transportcondition" value="Inproved|Worst|Unchanged"]


Hospital Arrival:
On arrival, we were directed to [select name="hospitalarr" value="bed|Triage"][text name="bednumber" default=""] as directed from the acting charge RN. Patient transferred to [select name="pttransferto" value="hospital bed|chair|wheelchair"] without incident.
Report: Patient care report given to RN [text name="RNname" default=""] at [select name="wherereportwasgivin" value="bedside|triage desk|nurse desk"];prior to signing for patient care, they were given the opportunity to ask any questions, state any comments or address any concerns
Signatures: [checkbox name="signature" value="obtained from patient|obtained from guardian/poa|obtained from responsible party|unable to sign|law enforcement signed as|nurse signed as|ems crew signed as| representative|witness|no representative available"][text name="pe_signature" default=" "][/conditional]

[conditional field="transportde" condition="(transportde).is('No Transport')"]
No Transport due to: 
[checkbox name="pe_trans_check" value="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"] to [text name="pe_trans" default="destination"][/conditional]

[text name="endunit" default="Medic 10"] clear and returned to service.

Name: [text name="rw" default=""]
Cert: [text name="rwcert" default=""]
[date name="date2" default="timestamp"]
Date of Run:
Run Number:

Crew Members:
/EVO
/Primary Care Provider



Disptached:
was dispatched by out to above address in reference to for
. Unit responded in an according to the above location. We

Complaint:
Patient was complaining of
Patient was found


HX:

Patient's medical history, medications, and allergies documented in appropriate section.

Assessment:
Appearance:
-Airway:
-Breathing:
-Circulation:
-Level of consciousness:
-HEENT:
-Cardiovascular:
-Respiratory:
-ABDOMEN:
-MSK:
-Skin:
-Neuro:
-Psych:

ALS Assessmement:


Treatment:
-Treatment included

-IV:
-12-Lead:

-Medcations Givien:
BLS Medication:

ALS Medication:




Decision to Transpot:






clear and returned to service.

Name:
Cert:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.49, 77 form elements, 92 boilerplate words, 33 text boxes, 5 text areas, 2 dates, 23 checkboxes, 1 radio buttons, 11 drop downs, 2 conditionals, 378 total clicks
Questions/General site feedback · Help Ticket

2 responses to “Luzerne County EMS 911 Narrtive”

Send Feedback for this SOAPnote

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

More SOAPnotes by this Author: