NWKAX 911

EMS DISPATCHED FOR [text name="dispatch" size = 55 default=" "].

RESPONDING UNIT: MED [select name="unit" value="1|2|4|5|6|RESPONSE"] [checkbox name="arrival" value="STAGING PRIOR TO ARRIVAL ON-SCENE|ARRIVED ON SCENE W/O INCIDENT|NO CHANGE IN RESPONSE MODE|EXPEDITE/UPGRADE RESPONSE|DELAY/DOWNGRADE RESPONSE|CANCELED ENROUTE|CANCELED ON-SCENE - NO PATIENT CONTACT"] 

EMS CREW APPLIED PPE OF: [checkbox name="PPE" value="HI-VIS SAFETY VEST|GLOVES|ISOLATION GOWN|GOGGLES/FACE SHIELD|SURGICAL MASK|N95|RESPIRATOR/HALO"]

SCENE DESCRIPTION: [textarea name="SCENE" size = 55 default=" "]
REQUESTED ASSISTANCE: [checkbox name="HELP" value="NONE|ADDITIONAL AMBULANCE|LIFT ASSIST|HAZMAT|FIRE/RESCUE|LAW ENFORCEMENT|CPR/CODE BLUE"]

PATIENT APPEARANCE: [checkbox name="pe_general" value="WELL DEVELOPED|WELL NOURISHED|WELL APPEARING|IN NO ACUTE DISTRESS|IN ACUTE DISTRESS|MALNOURISHED|OBESE|APPEARS ILL|APPEARS FRAIL|OBVIOUS SIGNS OF DEATH"][text name="pe_general_text" size = 75 default=" "]

INITIAL ABC's/COGNITION/PSYCH:
-AIRWAY: [checkbox name="airway" value="MAINTAINED BY PATIENT|NO CONCERNS OF COMPROMISE|AIRWAY PATENT|NO AIRWAY OBSTRUCTIONS|OXYGEN PLACED PRIOR TO ARRIVAL - REFER TO FLOWCHART TAB OF THIS EPCR|CONCERNS OF COMPROMISE|COMPROMISED|AIRWAY POSITIONED TO OPEN|AIRWAY NOT PATENT|OBSTRUCTIONS TO AIRWAY|REQUIRES AIRWAY ADJUNCT|REQUIRES ADVANCED AIRWAY|REQUIRES ARTIFICIAL VENTILATION"][text name="airway_text" size = 75 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|LABORED|APNEIC"][text name="breathing_text" size = 75 default=" "]

-CIRCULATION: [checkbox name="circulation" value="NO CONCERNS OF CIRCULATION|NO OBVIOUS BLEEDING|PULSES INTACT|SKIN COLOR APPROPRIATE|NO LIFE THREATS TO CIRCULATION|OBVIOUS BLEEDING|HEMORRHAGE PRESENT|HEMORRHAGE CONTROLLED|TOURNIQUET APPLIED|PULSES NOT INTACT|SKIN COLOR NOT APPROPRIATE|LIFE THREATENING CONCERNS WITH CIRCULATION|PULSES WEAK|PULSES BOUNDING"][text name="circulation_text" size = 75 default=" "]

-LEVEL OF CONSCIOUSNESS: [checkbox name="consciousness" 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_text" size = 75 default=" "]

-NEURO: [checkbox name="ros_neuro" value="GROSSLY ORIENTED X 4|ANSWERS ALL QUESTIONS SWIFTLY, CLEARLY AND CONGRUENTLY|GAIT STEADY & BALANCED|SENSATION INTACT WITH NORMAL REFLEXES|SMILE SYMMETRICAL|SPEECH NOT SLURRED|STRENGTH SYMMETRICAL|NEURO NOT GROSSLY INTACT|APHAGIA|APHASIA|DECEBERATE POSTURING|DECORTICATE POSTURING|SEIZURE ACTIVITY|STRENGTH ASYMMETRICAL|GAIT ABNORMAL|GAIT NOT ASSESSED DUE TO PT WEAKNESS|SENSATION ABSENT|SENSATION ABNORMAL|NO REFLEXES|SMILE ASYMMETRICAL|HEMIPLEGIA|HEMIPARESIS|SLURRED SPEECH|DELAYED VERBAL RESPONSES|OBTUNDED|UNRESPONSIVE, UNCONSCIOUS, PULSELESS, AND 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="ros_neuro_text" size = 75 default=" "]

-PSYCH: [checkbox name="ros_psych" value="PLEASANT|CALM|COOPERATIVE|JUDGEMENT INTACT|INSIGHT INTACT|UNDERSTANDS TREATMENT|THOUGHT PROCESS IS LOGICAL/LINEAR|THOUGHT PROCESS IS ILLOGICAL/INCONSISTENT|THOUGHT PROCESS IS AGE APPROPRIATE|AFFECT WITHIN NORMAL RANGE|THOUGHT PROCESS IS NOT AGE APPROPRIATE|CONSTRICTED/ABNORMAL AFFECT|SUICIDAL IDEATIONS|HOMICIDAL IDEATIONS|HAS A PLAN MADE|UNPLEASANT|NOT CALM|DOES NOT HAVE A PLAN|DOES NOT UNDERSTAND TREATMENT|JUDGEMENT NOT INTACT|INSIGHT NOT INTACT|IMPAIRED ATTENTION/CONCENTRATION|MOOD INSTABILITY|BASELINE FOR PT|UNRESPONSIVE|UNCONSCIOUS|UNRESPONSIVE, UNCONSCIOUS, PULSELESS, AND 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="ros_psych_text" size = 75 default=" "]

TRIAGE: [checkbox name="triage_check" value="GREEN - TRAUMA|YELLOW - TRAUMA|RED - TRAUMA|BLUE - TRAUMA|BLACK - TRAUMA|GREEN - MEDICAL|YELLOW - MEDICAL|RED - MEDICAL|BLUE - MEDICAL|BLACK - MEDICAL"]

CC: [text name="CC_text" size = 75 default=" "]

APPROX. TIME of CC: [text name="CCTIME_TEXT" size = 7 default=" "][select name="CCTIME_DROP" value="MINUTES|HOURS|DAYS|WEEKS|MONTHS|YEARS"]
SIGNS/SYMPTOMS REPORTED: [textarea name="siandsy_text" size = 55 default=" "]
EVENTS SURROUNDING CONDITION: [textarea name="events_text" size = 55 default=" "]
PERTINENT HX/REPORT: [textarea name="pertinent_hx_text" default=" "]

ASSESSMENTS: [checkbox name="assessments" value="DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE|UNABLE TO ASSESS TO DUE TO COMBATIVE STATE|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|WERE PERFORMED - PLEASE REFER TO ASSESSMENTS TAB IN THIS EPCR TO VIEW"][text name="assessments_text" size = 75 default=" "]

TREATMENTS: [checkbox name="treatment" value="NONE|MEDICAL TRANSPORT|ALS ASSESSMENT - PLEASE REFER TO ASSESSMENTS TAB IN THIS EPCR TO VIEW|BLS ASSESSMENT - PLEASE REFER TO ASSESSMENTS TAB IN THIS EPCR TO VIEW|WERE PERFORMED - PLEASE REFER TO FLOWCHARTS TAB IN THIS EPCR TO VIEW"][text name="treatments_text" size = 75 default=" "]

HOSPITAL ACTIVATIONS: [checkbox name="act_check" value="STROKE ALERT|TRAUMA ALERT|SEPSIS ALERT|CARDIAC ALERT|NO ALERTS ACTIVATED|RADIO REPORT PROVIDED TO RECEIVING OF PT COMPLAINTS, VITALS, TRIAGE, & ETA|CELLULAR REPORT PROVIDED TO RECEIVING OF PT COMPLAINTS, VITALS, TRIAGE, & ETA"][text name="act_text" size = 75 default=" "]

DISPOSITION: [checkbox name="dispo_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|PATIENT REFUSED EMS EVALUATION & TRANSPORT|PATIENT REFUSED EVALUATION|PATIENT 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="dispo_text" size = 75 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_text" size = 75 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_text" size = 75 default=" "]

NURSE RECEIVING PATIENT: [text name="Nurse" size = 40 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=" "]
EOR
EMS DISPATCHED FOR .

RESPONDING UNIT: MED

EMS CREW APPLIED PPE OF:

SCENE DESCRIPTION:
REQUESTED ASSISTANCE:

PATIENT APPEARANCE:

INITIAL ABC's/COGNITION/PSYCH:
-AIRWAY:

-BREATHING:

-CIRCULATION:

-LEVEL OF CONSCIOUSNESS:

-NEURO:

-PSYCH:

TRIAGE:

CC:

APPROX. TIME of CC:
SIGNS/SYMPTOMS REPORTED:
EVENTS SURROUNDING CONDITION:
PERTINENT HX/REPORT:

ASSESSMENTS:

TREATMENTS:

HOSPITAL ACTIVATIONS:

DISPOSITION:

MOBILITY ON SCENE:

MOBILITY AT DESTINATION:

NURSE RECEIVING PATIENT:



REPORT WRITER:
EOR

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.48, 42 form elements, 61 boilerplate words, 18 text boxes, 4 text areas, 18 checkboxes, 2 drop downs, 250 total clicks
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