MCEMS Narrative

Dispatch:[comment memo="How was it was dispatched? What was it dispatched as? "]
EC[select name="number" value="|1|2|3|4|5|6|7|8|9|10|11|12|13|14"] dispatched and responded [select name="how" value="|emergent|non-emergent"] to the above address for a: [select name="dispatched" value="|911|emergent interfacility transfer|non-emergent interfacility transfer|non-emergent transfer"]- 
[textarea name="variable_4" default=""]
Arrival:[comment memo="Scene assessment, patient location, A/O?, GCS-normal/abnormal?, current condition."]
[textarea name="arrival" default="Upon arrival"]
Chief Complaint:[comment memo="In patient's own words, what the PCS/family/friend/bystander states current issue."]
[textarea name="variable_5" default=""]
[checkbox memo="" name="VAC333" value="Pain:"][conditional field="VAC333" condition="(VAC333).is('Pain:')"]
Onset: [text name="pain" default=""]. Provocation: [text name="pain1" default=""]. Quality: [text name="pain2" default=""]. Radiation: [text name="pain3" default=""]. Severity: [text name="pain4" default=""]. Time: [text name="pain5" default=""].[/conditional]
History:
[textarea name="variable_6" default="Past medical history, medications, and allergies as noted."]
Assessment:[comment memo="Primary/Secondary/Ongoing assesmment. Paint clear picture. Make sure assessment and narrative match. Diagnostic results. If status changes or medication/fluids given, input secondary/ongoing assessment."]
[textarea name="variable_7" default="Primary assessment as noted. ALS assessment as noted. COVID-19 assessment as noted."]
[checkbox memo="" name="VAC777" value="Assessment Findings-"][conditional field="VAC777" condition="(VAC777).is('Assessment Findings-')"][checkbox name="variable_1" value="Patient is alert and oriented to person, place, time, and event.|Patient is alert, but disoriented.|Patient is arousable to verbal stimuli.|Patient is arousable to painful stimuli.|Patient is unresponsive.|Patient is intubated and sedated.|Patient orientation changed during transport|GCS normal for patient|GCS abnormal for patient|Patient status changed due to treatment/stimulation.|Patient status changed due to condition.|Patient status remained unchanged.|Patient's airway is open and maintained w/ no concern for compromise.|Patient's airway is not open and compromised, requiring intervention.|Patient's breathing is spontaneous, non-labored, with regular depth and rate.|Patient's breathing is abnormal and not adequate for perfusion.|Patient's circulation is a normal rate and quality.|Patient's circulation is critical w/ massive hemorrhage requiring intervention.|Skin WPD|Skin Pale|Skin Hot|Skin diaphoretic|Skin PCD"][/conditional]
[checkbox memo="" name="VAC888" value="Treatment:"][conditional field="VAC888" condition="(VAC888).is('Treatment:')"][comment memo="Any/all treatment done. Make sure it's in flowchart."]
[checkbox name="variable_111" value="Airway intervention was required as a lifesaving intervention.|Airway intervention and oxygen administration required as a lifesaving intervention.|Oxygen administration required due to patients status/vitals.|Oxygen administration required for patient comfort.|Patient was placed on cardiac and hemodynamic diagnostics for continuous monitoring.|Patient placed on hemodynamic monitoring.|12-lead placed due to possible cardiac related event|IV access withheld due to patient request|IV access withheld due to existing access|IV access was established by sending facility|IV access was successfully established in anticipation of medication or fluid administration.|IV access was successfully established for medication administration.|IV access was successfully established for fluid administration.|IV access was successfully established for medication and fluid administration.|IV access was unsuccessful, then successful for medication and fluid administration.|IV access was unsuccessful, then successful for anticipation of medication and fluid administration.|IV access was unsuccessfully established in anticipation of medication or fluid administration.|IO access established successfully for medication or fluid administration.|The sending facility required medication administration during transport.|Medications in flowchart given to patient due to current condition.|Manual CPR performed.|Manual CPR and mechanical CPR performed.|CPR initiated and discontinued due to patient status.|ACLS protocols followed.|Patient required c-collar for spinal precautions.|Patient required c-collar and backboard for spinal precautions|Patient placed on backboard/scoop stretcher for safe patient movement.|Patient required bandaging/tourniquet for hemorrhage control.|Patient required bandaging due to injury.|Patient required icepack due to injury.|Patient required splinting due to injury."][/conditional]
[checkbox memo="" name="VAC999999" value="Medication given:"][conditional field="VAC999999" condition="(VAC999999).is('Medication given:')"] [checkbox name="variable_35" value="withheld due to patient status|withheld due to patient vitals|withheld due to contraindication|withheld due to patient request/refusal|activated charcoal|adenosine|albuterol|ancef|aspirin|ativan|atropine|benadryl|calcium chloride|cardizem|amiodarone|dextrose 10%|dilaudid|dopamine|epinephrine|glucagon|NS|LR|lasix|lidocaine|metoprolol|magnesium sulfate|morphine|narcan|nitroglycerin|oral glucose|sodium bicarbonate|solu-medrol|thiamine|TXA|versed|zofran|propofol|insulin|TPA|heparin|blood|keppra|norepinephrine|vasopressin|ketamine|fentany|pitocin"][/conditional]
[textarea name="variable_18" default="Treatment details as noted in Flowchart."]
[checkbox memo="" name="VAC555555" value="Transport:"][conditional field="VAC555555" condition="(VAC555555).is('Transport:')"]
Patient transferred to [select name="variable_10" value="|stretcher|captains seat|bench seat|pediatric restraint system"] via [select name="variable_1" value="|ambulation|self-ambulation|sheet    drag|stairchair|sheet|backboard|scoop stretcher|mega    mover|carry|stand and pivot|body lift|wheelchair|rollator"][select name="variable_11" value="|x1|x2|x3|x4|x5|x6"] and secured. En route to [select name="variable_17" value="|BHR ER|SJB ER|SJE ER|SJM ER|SJL ER|UK ER|Good Sam ER|Baptist Health Lexington ER|Baptist Health Hamburg ER|VA ER|Marcum Wallce ER|Clark Regional ER|Ephraim McDowell|SJL|BHR|SJB|SJE|SJM|UK|Good Sam|VA|Baptist Health Lexington|Residence|Madison Health and Rehab|Kenwood|Telford Terrace|McCready Manor|Berea Terrace|Berea Health and Rehab|Dominion|Morning Pointe|Arcadian Cove|Compassionate Care|DCI|FMC Richmond|FMC Berea|Dr's Office|Other"] [select name="variable_19" value="|emergent|non-emergent"], patient status [select name="variable_20" value="|improved|remained unchanged|declined"]. Vitals taken and reassessed as noted. Upon arrival to destination, patient transferred from stretcher to [select name="variable_29" value="|hospital bed|bed|couch|recliner|rollator|wheelchair"] via [select name="variable_21" value="|sheet|self scoot|stand and pivot|ambulation|backboard|scoop stretcher|carry|wheelchair|stairchair|body lift|mega mover"][select name="variable_28" value="|x1|x2|x3|x4|x5|x6"] and secured. Bedside report given, care transferred to [select name="variable_31" value="nursing staff|patient|POA|legal guardian"].[/conditional]
[checkbox memo="" name="VAC111111" value="Movement of patient reason:"][conditional field="VAC111111" condition="(VAC111111).is('Movement of patient reason:')"]
[select name="variable_61" value="|patient weakness from current condition|patient weakness from noted medical hx|patient status|patient capability|patient request"][/conditional]
[checkbox memo="" name="VAC222222" value="Refusal:"][conditional field="VAC222222" condition="(VAC222222).is('Refusal:')"]
The [select name="variable_22" value="patient|legal guardian|POA|nurse"] has refused to be transported to the hospital for further evaluation and care. The[select name="variable_23" value="patient|legal guardian|POA|nurse"] is  oriented, clear of mind, and has the capacity to understand the presented information. The patient has verbalized full understanding of their symptoms  and understands that forgoing further evaluation and/or treatment could pose a significant medical risk to the patient's life. The patient has verabalized that they understand our treatment plan, including interventions and transport destinations, and does not want these interventions currently. Furthermore, the [select name="variable_24" value="patient|legal guardian|POA|nurse"] acknowledges that forgoing this treatment could lead to worsening of condition up to and including death. The [select name="variable_25" value="patient|legal guardian|POA|nurse"] understands that they are free to call 911 should the condition worsen, or they later decide that they wish to be transported to the Emergency Department for further evaluation and intervention. The [select name="variable_26" value="patient|legal guardian|POA|nurse"] acknowledges and signed the EMS Refusal Form.[/conditional]
[checkbox memo="" name="VAC333333" value="Exceptions:"][conditional field="VAC333333" condition="(VAC333333).is('Exceptions:')"]
[text name="variable271" default=""][/conditional]
[checkbox memo="" name="VAC3333" value="Student Ride Time:"][conditional field="VAC3333" condition="(VAC3333).is('Student Ride Time:')"]
[select name="variable_121" value="|Paramedic|AEMT|EMT"] student was supervised giving patient interventions/treatments/assessments by the lead provider [text name="variable_321" default=""].[/conditional]
SmartDocs:[comment memo="Only 1 required (can do pain/OPQRST assessment either in Chief Complaint section OR SmartDocs) unless being transferred. Select 2 if transfer."][link url="https://mnc.smartdocsolutions.com/" memo="SmartDocs Home"]
[textarea name="variable_1" default="" text"]
[comment memo="Don't forget to fill out all assessments, flowchart items, vitals, and credentials!"]