MOIMSD ER Visit

• Date & Time of Arrival: [date name="variable_1" default="timestamp"]
• Arrived:[checklist value="Walking"] [checklist value="Wheel Chair"] [checklist value="Ambulance"] [checklist value="Police"] [checklist value="Carried"]
• Assisted by: [checklist value="Self"] [checklist value="relative/Freind"]
• Allergies: [select name="variable_4" value="No|Yes"][conditional field="variable_4" condition="(variable_4).is('Yes')"] [text name="variable_5" default="specify:"][/conditional]
• Tetanus Toxoid: [select name="variable_6" value="No|Yes,"][conditional field="variable_6" condition="(variable_6).is('Yes,')"] [text name="variable_7" default="Year:"][/conditional]
[checkbox memo="♀"  memo_style="bold-italic" memo_color="purple" name="VAC111111" value="• Female,"][conditional field="VAC111111" condition="(VAC111111).is('• Female,')"][select name="variable_8" value="Not Pregnant|Pregnant"][conditional field="variable_8" condition="(variable_8).is('Pregnant')"]  [text name="variable_9" default="Weeks:"][/conditional][/conditional]
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• Vital Signs & Pain Assesment was reviwed. [checkbox name="VAC" value="Comment:"][conditional field="VAC" condition="(VAC).is('Comment:')"] [textarea cols=61 rows=1  size=30][/conditional]
• Presenting Complain: [textarea cols=61 rows=1  size=30]
• History: [textarea cols=61 rows=5  size=30]
• Physical Assesment: [textarea cols=61 rows=5  size=30]
• Triage Level: [checklist value="(4)Non-Urgent"] [checklist value="(3)Urgent"] [checklist value="(2)Emergent"] [checklist value="(1)Life-Threatening"]
• Impression/Diagnosis: [textarea cols=61 rows=1  size=30]
• Investigation: [textarea cols=61 rows=1  size=30]
• Treatment/Fist Aid Given:[textarea cols=61 rows=5  size=30]
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• Re-Assesment: [textarea default="Time:    Patient is Stable" cols=61 rows=2  size=30]
• Re-Triage Level: [checklist value="(4)Non-Urgent"] [checklist value="(3)Urgent"] [checklist value="(2)Emergent"] [checklist value="(1)Life-Threatening"]
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• Decision Taken: [select name="Decision" value="Discharged|Referred"][conditional field="Decision" condition="(Decision).is(Discharged)"] [text name= default=",Time:"][conditional field="Decision" condition="(Decision).is(Referred)"] [text name= default=",Time:"][/conditional]
• Patient Condition on discharge: [checklist value="Good"] [checklist value="Fair"] [checklist value="Serious"] [checklist value="Critical"] [checklist value="Death"]
[comment memo_color="Green" memo_style="bold-italic" memo_size="small" memo="Good: Vital signs are stable and within normal limits. Patient is conscious and comfortable."]
[comment memo_color="yellow" memo_style="bold-italic" memo_size="small" memo="Fair: Vital signs are stable and within normal limits. Patient is conscious but may be uncomfortable."]
[comment memo_color="darkorange" memo_style="bold-italic" memo_size="small" memo="Serious: Vital signs may be unstable and not within normal limits. Patient is acutely ill."]
[comment memo_color="red" memo_style="bold-italic" memo_size="small" memo="Critical: Vital signs are unstable and not within normal limits. Patient may be unconscious."]