-----Dispatch & Scene-----
Dispatched to a [text name="dispatchcall" default=""] call from [select name="variable_1" value="Base 1|Base 2|Base 3|Base 4"] with prearrival instructions given en route. Unit [select name="unitnumber" value="1171|1172|1181|1191"] responded [select name="traffic" value="without lights and sirens|with lights and sirens"], without incident.
Scene size up: [text name="variable_1" default=""]
All EMS personnel wore appropriate PPE before making contact with the patient, including face mask (surgical, non-fitted) and gloves.

History of Present Issue: [text name="age" default=" year-old"] [select name="sex" value="female|male|nonbinary"]
[textarea name="HPI" default=""]
Past Medical History: [textarea name="PMH" size = 55 default=""]
Medications: [textarea name="medications" size = 55 default=""]
Allergies: [text name="allergies" size = 55 default="NKDA"]
Social History: [checkbox name="SocialHistory" value="Denies drug use|Denies EtOH use|Does not smoke cigarettes|Endorses EtOH use|Endorses recreational drug use.|Cigarette smoker|Former cigarette cmoker|Substance abuse in recovery|Not obtained"]
[text name="socdetails" default=""]

Review of Systems:
Psych: [text name="psych" default="No reported recent or active suicidality or homicidal ideations. No reported recent or active visual/auditory disturbances."]
HEENT: [text name="HEENT" default="No change in vision, hearing, and no symptoms of an upper respiratory tract infection."]
CNS: [text name="CNS" default="No reported headache or neurologic symptoms."]
Cardiovascular: [text name="cardiovascular" default="No reported palpitations, chest pain or discomfort."]
Pulmonary: [text name="PULM" default="No reported SOB, cough, or increased work of breathing."]
GI/GU: [text name="GIGU" default="No reported nausea or vomiting, bowel habits, or changes in voiding urine."]
Musculoskeletal: [text name="msk" default="No reported musculoskeletal pain or injuries. "]
[checkbox name="OBGYN" value="OBGYN:"][conditional field="OBGYN" condition="(OBGYN).is('OBGYN:')"] [select name="OB" value="Denies possibility of pregnancy.|Endorses possibility of pregancy.|Pregnant.|Post-menopausal."] [text name="OB" default=""]

Physical Exam
General: [textarea name="general" default="Alert to voice, interacts appropriately with medical staff; in no acute distress. Gait is steady. Speech is not slurred."]
The patient was found in a [select name="position" value="semi-fowler|supine|prone|right lateral|left lateral|sitting"] position [select name="location" value="in a chair|in a recliner|in the bed|on the edge of the bed|on the floor|on the ground|on the couch|on the toilet|in the shower| "][text name="foundposition" default=""]
The patient was dressed [text name="dressed" default="fully and appropriately for the weather"]
Airway: [select name="airway" value="open, patent, without obstruction|airway positioned to open|airway not patent|obstructions to airway|requires airway adjunct|requires advanced airway|requires assisted ventilation"]. 
Breathing: [select name="breathing" value="spontaneous, regular, adequate, without any apparent life threats to breathing, normal work of breathing on room air|irregular|not spontaneous|inadequate|normal|slow|shallow|fast|deep|labored|agonal|absent"]. 
Circulation: [select name="circulation" value="regular, strong pulse without major hemorhage noted|irregular|tachycardic|bradycardic|weak pulse|massive hemorrhage|diminished perfusion|pulseless| "]. 
Skin: [checkbox name="skin" value="pink, warm, dry |pale, cool, clammy|hot, flushed|cyanotic|lividity|jaundiced"]
Head: [textarea name="head" default="Atraumatic, normocephalic, Pupils equally round/reactive at 4mm in size. No facial droop. Mucous membranes are moist."]
Neck: [text name="NECK" default="Trachea midline, no JVD, no noted trauma."]
Chest: [textarea name="chest" default="Normal work of breathing on room air, clear to auscultation bilaterally."]
Back: [text name="back" default="No stepoffs or deformities, no bruising or major trauma. "]
Abdomen: [textarea name="abd" default="Soft, non -tender, non-distended with no guarding, rigidity, or rebound tenderness."]
Pelvis: [textarea name="pelvis" default="Stable, no incontinence noted."]
Extremities: [textarea name="extremities" default="No noted trauma. No clubbing, cyanosis, or edema."]
Vitals: [select name="vital" value="As documented previously"][textarea name="vitals" default=""]
[comment memo="EKG IF OBTAINED"][select name="EKG" value=" | 12 lead EKG:|4 lead EKG: "][select name="EKG" value="Sinus Rhythm|Sinus Bradycardia|Sinus Tachycardia|Sinus Arrhythmia|Wandering Atrial Pacemaker|Multifocal ATach|AFIB|AFIB w/RVR|Supraventricular Tachycardia|Aflutter|Junctional Rhythm|First Degree AV Block|Second Degree Type 1|Second Degree Type 2|3rd Degree Block|IVR|Accelerated IVR|VTach|VFib|Asytole|PEA|Torsades"][checklist name="variable_1" value="with PVCs|with PACs|with PJCs"][text name="text" default=""]
Cardiac Interventions: [textarea name="text" default=""]
Additional Findings: [textarea name="additional" default="N/A"]
GCS: [select name="GCS" value="15|14|13|12|11|10|9|8|7|6|5|4
3|3T"]; eyes: [select name="eyes" value="4 (open spontaneously)|3 (open to verbal)|2 (open to pain)|1 (do not open)"]; verbal: [select name="verbal" value="5 (oriented)|4 (confused)|3 (inappropriate responses, words discernible)|2 (incomprehensible sounds or speech)|1 (no verbal response)"]; motor = [select name="motor" value="6 (obeys commands)| 5 (purposeful movement to painful stimulus)| 4 (withdraws from pain)|3 (decorticate)|2 (decerebrate)|1 (no motor response)"]

Impression(s): [text name="age" default=" year-old"] [select name="sex" value="male|female|nonbinary"] [textarea name="impression" default=""]

-----Plan & Transportation-----
[textarea name="treatment" default=" "]
    Airway & Oxygen: [text name="airway&oxygen" default=" "]

IV Access
[select name="size" value="14g|16g|18g|20g|22g|24g"] in the [select name="leftright" value="left|right"] [select name="variable_1" value="AC|Bicep|Hand|Forearm|Radial"]
Number of Attempts:[text name="attemptsIV" default="1"]
Successful?: [select name="success" value="Yes|No"]
No irritation noted, IV flushed easily and drewback.

[select name="variable_39" value="The patient wore an appropriate face mask|Given the acuity of this patient's condition, a facemask was not applied"]
The patient [select name="variable_64" value="walked without assistance to the stretcher|walked with assistance to the stretcher|was sheet lifted to the stretcher|assisted patient to the stair chair, secured with safety straps, and moved to stretcher, then patient stand and pivoted to stretcher"] and then the patient was secured to the stretcher with seatbelts secured and transported in the [select name="travelposition" value="semi-fowler position|supine|sitting upright"]. [checkbox name="blanket" value="The patient was covered with a blanket"]. 
Transport [select name="urgency" value="non-emergent|emergent|upgraded to emergent"] to [select name="destination" value="the hospital|CCH|UNC-Chapel Hill|UNC-Hillsborough|Duke Main|Duke Regional|Granville|Moore Regional"] with pre-arrival [select name="callin" value="notification|Trauma Alert|Stroke Alert|Cardiac Alert| "] made en route. [textarea name="trnspt" default="During transport, the patient remained stable."]

Hospital Arrival:
The patient was brought inside the hospital via [select name="transpomode" value="stretcher|wheelchair|self ambulation"] and then the patient was [select name="variable_111" value="sheet-lifted|patient scooted|Hoyer lifted|stood and pivoted without assistance|stood and pivoted with assistance|walked unassisted|walked with assistance"] to assigned hospital bed.

[select name="ptsign" value="The patient signed the PCR.|Patient was unable to sign PCR.|Equipment failure/malfunction prevented signature."][text name="signdetails" default=""]
[textarea name="hosp" default="Upon arrival to the ED, handoff was given to nurse and provider at bedside. Nurse signed PCR. Care was transferred at that time."]

Out of County Mileage: [text name="outofcountymileage" default="0 miles"]
-----Dispatch & Scene-----
Dispatched to a call from with prearrival instructions given en route. Unit responded , without incident.
Scene size up:
All EMS personnel wore appropriate PPE before making contact with the patient, including face mask (surgical, non-fitted) and gloves.

History of Present Issue:

Past Medical History:


Social History:

Review of Systems:

Physical Exam

The patient was found in a position
The patient was dressed
Airway: .
Breathing: .
Circulation: .






Cardiac Interventions:

Additional Findings:

GCS: ; eyes: ; verbal: ; motor =


-----Plan & Transportation-----

Airway & Oxygen:

IV Access
in the
Number of Attempts:
No irritation noted, IV flushed easily and drewback.


The patient and then the patient was secured to the stretcher with seatbelts secured and transported in the . .
Transport to with pre-arrival made en route.

Hospital Arrival:
The patient was brought inside the hospital via and then the patient was to assigned hospital bed.

Out of County Mileage:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.48, 77 form elements, 169 boilerplate words, 23 text boxes, 16 text areas, 4 checkboxes, 1 check lists, 31 drop downs, 1 comments, 1 conditionals, 90 total clicks
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