OHSaggyEMS

[comment memo="THIS IS AN INTERACTIVE PATIENT CARE REPORT TEMPLATE. FILL IT OUT/MAKE EDITS AS NEEDED, THEN CLICK CALCULATE RESULT AT THE BOTTOM AND COPY/PASTE INTO YOUR NARRATIVE SECTION. YOU CAN FINISH EDITING IT THERE."]

[comment memo="NOTE: NOTHING ON THIS WEBSITE SAVES. COPY/PASTE THE TEMPLATE INTO YOUR CHART EARLY ON TO AVOID LOSING ANY WORK."]

DISPATCH: [select name="LEVEL_OF_CARE" value="BLS|MEDIC"] [text name="UNIT" default="611,621,631,632"] IS DISPATCHED TO  [text name="ADDRESS" default="ADDRESS"] FOR [text name="DISPATCH" default="AGE, SEX"] AND RESPONDS  [select name="RESPONSE_TYPE" value="NON-EMERGENCY|EMERGENTLY"] WITH [conditional field="LEVEL_OF_CARE" condition="(LEVEL_OF_CARE).is('BLS')"]A BLS[/conditional][conditional field="LEVEL_OF_CARE" condition="(LEVEL_OF_CARE).is('MEDIC')"]AN ALS[/conditional] CREW OF [text name="NUMBER_OF_CREW" default="2"].[textarea name="ADDITIONAL_NOTES" default=""]

CHIEF COMPLAINT: [text name="CHIEF_COMPLAINT" default="""]

SCENE ARRIVAL: [textarea name="SCENE" default="UPON ARRIVAL,   PT IS FOUND: "]

HISTORY: (Hx, Rx, ALLERGIES AS NOTED) - [textarea name="HISTORY" size = 55 default="PT STATES:  PT DENIES: "]

ASSESSMENT:
GENERAL: [textarea name="APPEARANCE" default="A/O X4. INTERACTING WITH EMS APPROPRIATELY; WELL APPEARING; NOT ACUTELY DISTRESSED. "]
AIRWAY/BREATHING: [textarea name="AIRWAY" default="NO IMMEDIATE CONCERNS. AIRWAY IS PATENT AND CLEAR OF OBSTRUCTIONS. NORMAL AND ADEQUATE RATE/DEPTH."] [checkbox name="LUNG_SOUNDS" value="LUNG SOUNDS PRESENT AND CLEAR BILATERALLY."]
CIRCULATION: [textarea name="CIRCULATION" default="NO IMMEDIATE CONCERNS. NO MAJOR HEMORRHAGE. EQUAL RADIAL PULSES BILATERALLY. "]
CNS: [textarea name="CNS" default="SPEECH IS NOT SLURRED. PMS GROSSLY INTACT IN ALL 4 EXTREMITIES. GAIT IS STEADY. "]
PSYCH: [textarea name="PSYCH" default="NO REPORTED RECENT OR ACTIVE SUICIDALITY OR HOMICIDAL IDEATIONS. NO REPORTED RECENT OR ACTIVE VISUAL/AUDITORY DISTURBANCES. "]
GI/GU: [textarea name="GIGU" default="NO NAUSEA OR VOMITING. NO CHANGES IN BOWEL OR URINE REPORTED. "]

[checkbox name="PHYSICAL_EXAM" value="PHYSICAL EXAM:"][conditional field="PHYSICAL_EXAM" condition="(PHYSICAL_EXAM).is('PHYSICAL EXAM:')"]
HEAD: [textarea name="HEAD" default="NO NOTED PAIN OR TRAUMA. NO FACIAL DROOP. "][checkbox name="PUPILS" value="PUPILS EQUALLY ROUND AND REACTIVE."]
NECK: [textarea name="NECK" default="NO NOTED PAIN OR TRAUMA. NO JVD. TRACHEA MIDLINE. "]
CHEST: [textarea name="CHEST" default="NO NOTED PAIN OR TRAUMA. EQUAL RISE AND FALL. BREATH SOUNDS CTA BILATERALLY. "]
BACK: [textarea name="BACK" default="NO NOTED PAIN OR TRAUMA. "]
ABDOMEN: [textarea name="ABD" default="NO NOTED PAIN OR TRAUMA. SOFT, FLAT, NON-TENDER. "]
PELVIS: [textarea name="PELVIS" default="NO NOTED PAIN OR TRAUMA. STABLE. "]
EXTREMITIES: [textarea name="EXTREMITIES" default="NO NOTED PAIN OR TRAUMA. NO CLUBBING, CYANOSIS OR EDEMA. "]
SKIN: [textarea name="SKIN" default="NORMAL TONE FOR ETHNICITY, WARM, DRY. "]

[/conditional]VITALS: (AS NOTED IN REPORT) [textarea name="VITALS" default=" "][checkbox name="EKG" value=" 12 LEAD EKG ACQUIRED AND TRANSMITTED TO ED."]

TREATMENT: [checkbox name="treatment" value="PRIMARY AND SECONDARY ALS ASSESSMENT|PRIMARY AND SECONDARY BLS ASSESSMENT|CONTINUOUS CARDIAC MONITORING"] [textarea name="rxt" default=" "]

HOSPITAL ACTIVATIONS: [checkbox name="pe_act_check" value="ER CONTACTED FOR STROKE|ER CONTACTED FOR TRAUMA|THROMBOLYTIC CHECKLIST COMPLETED|HISTORIAN INFORMATION AND CONTACT NUMBER GATHERED|NO ALERTS ACTIVATED"][text name="pe_act" default=" "]

TRANSPORT: [checkbox name="pe_trans_check" value="SECURED PATIENT TO STRETCHER WITH 3 STRAPS AND RAILS UPRIGHT|LOADED INTO AMBULANCE FOR TRANSPORT|EMERGENCY|NON EMERGENCY|EMERGENCY DOWNGRADED TO NON EMERGENCY|NON EMERGENCY UPGRADED TO EMERGENCY|PATIENT REFUSED TRANSPORT|AMA|PATIENT TREATED AND RELEASED|NO TRANSPORT|LIFT ASSIST ONLY|TRANSPORTED TO SSM ST MARYS HOSPITAL|TRANSPORTED TO PHELPS MEDICAL CENTER|TRANSPORTED TO CAPITAL REGION MEDICAL CENTER|TRANSPORTED TO UNIVERSITY HOSPITAL COLUMBIA|TRANSPORTED TO MERCY WASHINGTON"][text name="pe_trans" default=" "]

REPORT:[checkbox name="REPORT" value="REPORT: [checkbox name="pe_rep_check" value="NONE|IN-BOUND PT REPORT GIVEN TO NURSE PRIOR TO ARRIVAL|IMPROVEMENT IN PATIENT CONDITION|DECLINE IN PATIENT CONDITION|NO CHANGE IN PATIENT CONDITION"][text name="pe_rep" default=" "]

ARRIVAL:[checkbox name="ARRIVAL" value="ARRIVAL:[checkbox name="ARRIVAL" value="NONE|PATIENT WAS BROUGHT INTO RECEIVING FACILITY ON THE STRETCHER AND WAS TAKEN TO THEIR ROOM. A THREE PERSON SHEET LIFT WAS USED TO TRANSFER PATIENT FROM STRETCHER TO MEDICAL BED W/O INCIDENT. A DETAILED REPORT WAS GIVEN TO THE RECEIVING RN.|PATIENT WAS BROUGHT INTO RECEIVING FACILITY ON THE STRETCHER AND WAS TAKEN TO THEIR ROOM. PT WAS ABLE TO AMBULATE TO MEDICAL BED WITH ASSISTANCE, A DETAILED REPORT WAS GIVEN TO THE RECEIVING RN. "]

SIGNATURES: [checkbox name="SIGNATURE" value="OBTAINED FROM PATIENT|OBTAINED FROM GUARDIAN/POA|NOT OBTAINED FROM PATIENT|SIGNED BY LAW ENFORCEMENT AS GUARDIAN|UNABLE TO SIGN|NO REPRESENTATIVE AVAILABLE|NURSE SIGNED AS WITNESS|NURSE SIGNED FOR TRANSFER OF PATIENT CARE"][text name="pe_SIG" default=" "]

[checkbox name="AMA" value="IN SPITE OF MULTIPLE ATTEMPTS BY MYSELF AND MY PARTNER TO CONVINCE THE PATIENT TO BE TRANSPORTED TO HOSPITAL FOR EVALUATION AND TREATMENT, WE HAVE UNFORTUNATELY BEEN UNSUCCESSFUL. HOWEVER, THE PATIENT HAS THE CAPACITY TO GIVE, RECEIVE, AND WITHHOLD INFORMATION. THE PATIENT VERBALIZES UNDERSTANDING OF THEIR CONDITION AND SYMPTOMS AND THAT REFUSING CARE COULD POSE SIGNIFICANT RISK TO THEIR LIFE. THE PATIENT 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 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."]

EMS BACK IN SERVICE
END OF REPORT
[comment memo="Enter Provider Name/Level"]
[text name="provider_name_and_level" default="BLAKE PAUL, EMT-B"]
THIS IS AN INTERACTIVE PATIENT CARE REPORT TEMPLATE. FILL IT OUT/MAKE EDITS AS NEEDED, THEN CLICK CALCULATE RESULT AT THE BOTTOM AND COPY/PASTE INTO YOUR NARRATIVE SECTION. YOU CAN FINISH EDITING IT THERE.

NOTE: NOTHING ON THIS WEBSITE SAVES. COPY/PASTE THE TEMPLATE INTO YOUR CHART EARLY ON TO AVOID LOSING ANY WORK.

DISPATCH: IS DISPATCHED TO FOR AND RESPONDS WITH CREW OF .


CHIEF COMPLAINT:

SCENE ARRIVAL:


HISTORY: (Hx, Rx, ALLERGIES AS NOTED) -


ASSESSMENT:
GENERAL:

AIRWAY/BREATHING:

CIRCULATION:

CNS:

PSYCH:

GI/GU:


VITALS: (AS NOTED IN REPORT)


TREATMENT:


HOSPITAL ACTIVATIONS:

TRANSPORT:

REPORT:

ARRIVAL:

SIGNATURES:



EMS BACK IN SERVICE
END OF REPORT
Enter Provider Name/Level

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.31, 48 form elements, 49 boilerplate words, 10 text boxes, 19 text areas, 11 checkboxes, 2 drop downs, 3 comments, 3 conditionals, 76 total clicks
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