Northfield Ambulance DCHART

DISPATCH:
Northfield Ambulance    [text name="ou" default="Truck"] was dispatched to above address in reference to [text name="AGE" default="AGE IN YEARS"] year-old [select name="gender" value="MALE|FEMALE"] for [text name="disp" default="Call Type"]. We responded in an [select name="respmode" value="emergent|non-emergent"] manner [select name="lights" value="with the use of lights and sirens.|without the use of lights and sirens."] We [select name="scene" value="arrived on-scene without incident.|were cancelled en route.|canceled on scene."] We found the patient [text name="ptfound" default="sitting upright..."].   If    applicable, the patient documentation was collected from    staff.

COMPLAINT:
Patient or family has a chief complaint of [text name="complaint" default="complaint"].  Information    was    collected    from    [select name="informant" value=the patient.|the family.|the staff.]  Additional complaint details included: [comment memo="No further details."]

HISTORY: 
The suspected [select name="MOI/NOI" value="MOI|NOI"]    is [text name="variable_1" default="sample text"].   This    includes    the following: [textarea name="Hx_for_complaint" default="History of what led up to EMS being called."] 
- O:    [text name="Onset" default="Onset"]
- P:    [text name="Provocation" default="Provocation"]
- Q:    [text name="Quality" default="Quality"]
- R:    [text name="Radiation" default="Radiation"]
- S:    [text name="Severity" default="Number"] out of 10 scale
- T:    [text name="Time" default="Time"]

Patient's medical history, medications, and allergies documented in appropriate section.    Pertinent    information    includes:    [textarea name="ample" default="Pertinent information regarding    allergies,    medications,    or history"] 

ASSESSMENT:
-Appearance: The    patient appers [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=" "].
-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=" "]
-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="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=" "]
-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=" "]
-Abdominal/GI&GU: [checkbox name="pe_gi_check" value="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=" "]
-Neuro: [checkbox name="pe_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|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=" "]
-HEENT: [checkbox name="pe_heent_check" value="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=" "]
-Muscleskeletal: [checkbox name="pe_msk_check" value="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="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=" "]
-Psych: [checkbox name="pe_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|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=" "]
-Primary    Vitals: BP -    [text name="SBP" default="SBP"]/[text name="DBP" default="DBP"];    HR -    [text name="HR" default="HR"]; RR - [text name="RR" default="RR"]; O2 sat - [text name="O2" default="O2"]    on [select name="variable_1" value="room    air|normal oxygen    level|increased oxygen"]; Temp - [text name="TEMP" default="TEMP"]F;    
Blood glucose - [text name="BGS" default="BGS"] mg/dL   

Rx - TREATMENT:
[select name="ALSBLS" value="BLS|ALS"] assessment was done on the patient. The patient was [select name="tostretcher" value="assisted|positioned|lifted"] to    the stretcher and placed in a [select name="position" value="semi-fowlers|supine|high fowlers"] position. A blanket was placed on the patient to maintain body temperature. Vitals were taken on the patient    and were monitored enroute.  12-lead ECG    was obtained.  IV access    was established via [text name="IVaccess" default="IV access    info"].  The    following medications were administered: [textarea name="meds" default="meds administered"].    The  additional treatments included:    [textarea name="freestyletreat" default="Treatment"]

Pre-Hospital activations: [checkbox name="pe_act_check" value="Stroke Alert|Trauma Alert|Sepsis Alert|STEMI Alert|no alerts activated"][text name="pe_act" default=" "]

TREATMENT:
[checkbox name="pe_trans_check" value="secured patient to stretcher with belts and rails|loaded into ambulance for transport w/o incident|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|supine|low fowler's|semi-fowler's|fowler's|full fowler's/sitting|transferred care to another ems unit - ground|transferred care to another ems unit - air"] to [text name="pe_trans" default="destination"]
On arrival, we were directed to [text name="hospassign" default="Bay#"]. Patient transferred to [select name="variable_1" value="hospital bed|chair|wheelchair"] without incident.
Report: Patient care report given to RN [text name="RNname" default="sample text"] at bedside;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=" "]

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

[text name="rw" default="Provider"]
[text name="rwcert" default="Cert"]
[text name="variable_1" default="agency"]