PIFT ECPR template

Arrived to [select name="Arrived-to" value="CMMC|St. Mary's|Cancer center at CMMC|Bolster Heights|Chapman House|Clover|D'Youville|pt home|Hospice house|Lamp Memory Care|Marshwood|Montello Manor/ Commons|Odd Fellows|Sarah Frye|Schooner|The Meadows|Woodlands|Maine Med.|Bridgeton|Midcoast|Maine General|Rumford|OTHER"].
Got reprot from [textarea name="Breif-reprot" default="RN- Brief report"] Pt is going to [select name="variable_1" value="Maine Med|CMMC.|St. Mary's.|Cancer center at CMMC|Maine Med.|Bridgeton|Midcoast|Maine General|Rumford|Mass Gen
|OTHER"] for [checkbox name="variable_1" value="further testing|further imaging|specilized care|further treatment|surgery|wound care|cancer appointment|appointment"]

Ambulance transport is medically necessary due to [text name="variable_1" default="Medical necessity"]. 

Patient specific orders from Dr. [text name="variable_1" default="sample text"] are [textarea name="variable_1" default="sample text"]. Orders where [checkbox name="variable_1" value="verbal|written and attached|to follow ACLS and Maine EMS protocol"]. This medic requested orders for [text name="variable_1" default="sample text"] and where [checkbox name="variable_1" value="granted|not granted|not granted but told to call ----- if orders where needed enroute"].

IV access [text name="variable_1" default="sample text"] remained clean dry and intact for duration of transport. 

Pt is on [text name="variable_1" default="---LPM o2 via NC"] [checkbox name="variable_1" value="at baseline|since admission to facility"]baseline. O2 transferred between facility, stretcher, and onboard as appropriate without need for titration.

Crew Found pt [select name="variable_1" value="laying semi fowlers in bed|Supine in bed|Sitting in a chair|walking around in room|walking to stretcher in hall|OTHER"]. 

Initial ABC's:

-Airway: [checkbox name="airway" value="airway open.|airway patent.|no airway obstructions.|Normal.|airway positioned to open.|airway not patent.|airway required suctioning."][text name="airway" default=" "]

-Breathing: [checkbox name="breathing" value="breathing spontaneously.|breathing regular.|adequate respirations|equal chest rise and fall.|Normal.|irregular respirations.|inadequate respirations.|apparent life threats to breathing.|unequal chest rise and fall|seesaw breathing|rib retractions present.|grunting with respirations.|pt is in a tripod position.|with no apparent life threats to breathing."][text name="breathing" default=" "] 

-Circulation: [checkbox name="circulation" value="no obvious bleeding.|pulses intact.x4|skin color appropriate.|cap refill <2 seconds.|no life treats to circulation.|normal.|hemorrhage present.|hemorrhage controlled.|TQ applied.|pulses not intact.|skin color not appropriate.|cap refill >2 seconds.|life threatening concerns with circulation."][text name="ros_constitutional" default=" "]


PHYSICAL EXAM:	

General: 
[checkbox name="pe_general_check" value="Alert & oriented x4.|Alert to time.|Alert to place.|Alert to person.|Altert to situatuion| in no acute distress.|Alert, but confused.|Well appearing.|malnourished.|in acute distress."][text name="pe_general" default=" "]

HEENT: 
[checkbox name="pe_heent_check" value="normocephalic.|atraumatic.|PEARL.|white sclera.|conjunctiva pink/red.|no fluid noted in or around ears.|no bleeding.|bleeding.|positive HALO test.|negative HALO test.|dry mucous membranes.|extra salivation. |normal mucous.|normal pharynx.|no trauma to mouth.|Normal.|trauma to face.|trauma to mouth.|patient denies vision changes.| patient denies ear pain.|no nasal congestion.| patient denies sore throat.|no cough.|Injuries are appropriately dressed per sending facility wishes and remained clean, dry, and intact for duration of transport."][text name="pe_heent" default=" "]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|mucosa pink & moist|mucosal edema|clear discharge|active septal hemorrhage|clotted blood|nasal flairing|Injuries are appropriately dressed per sending facility wishes and remained clean, dry, and intact for duration of transport."][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="normal inspection|moist oral mucosa without lesions or injury|no dental injury|upper denture|lower denture|mucosal laceration|dental injury|tongue deviation|dental decay|Injuries are appropriately dressed per sending facility wishes and remained clean, dry, and intact for duration of transport."][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="normal voice.|patent pharynx w/o swelling or exudates|uvula midline|paitent is nonverbal.|Injuries are appropriately dressed per sending facility wishes and remained clean, dry, and intact for duration of transport."][textarea cols=70 rows=1]

NECK:
[checkbox name="neck" value="no gross deformity or misalignment.|no vertebral tenderness.|pain with movement.|vertebral point-tenderness.|c-spine cleared by sending facility|cspine not clear|c-collar present and inplace.|c-collar not inplace, was replaced prior to movement.|Injuries are appropriately dressed per sending facility wishes and remained clean, dry, and intact for duration of transport."][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion.|non-tender.|clear and equal breath sounds bilaterally.|bruising|tenderness.|poor effort.|coughing.|----fail chest noted.|Injuries are appropriately dressed per sending facility wishes and remained clean, dry, and intact for duration of transport."][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="normal visual inspection, no distension.|soft non-tender|protruding.|surgical scar.|umbilical hernia.|diffuse tenderness over entire abdomen.|Injuries are appropriately dressed per sending facility wishes and remained clean, dry, and intact for duration of transport."][textarea cols=70 rows=1]

Neuro: 
[checkbox name="pe_neuro_check" value="Grossly oriented X 4.|gait normal.|sensation intact.|normal reflexes.|smile normal.|speech not slurred.|Normal.|Neuro not grossly intact.|gait abnormal.|sensation absent.|no reflexes.|smile not symmetrical.|slurred speech.|Injuries are appropriately dressed per sending facility wishes and remained clean, dry, and intact for duration of transport."][text name="pe_neuro" default=" "]


Pt was transferred to stretcher via [checkbox name="variable_1" value="2 provider drawsheet|3+ provider drawsheet|assisted self scoot|assisted stand and pivot|assisted walk|unassisted walk|OTHER"] and made comfortable and secured as appropriate. 

Pumped medications where[checkbox name="variable_1" value="kept on sending facility pumps set by sending facility and where not modified in anyway by crew|kept on sending facility pumps set by sending facility ------- where titrated as documented|where transfered to crews pumps, concentration, programed weight, and doses where varified by RN at sending facility. Medications where not titrated.|where transfered to crews pumps, concentration, programed weight, and doses where varified by RN at sending facility. Medications where titrated as documented."]

Gravity medications [text name="variable_1" default="WHERE NOT IN USE"]

In unit pt was monitored as recorded and [checkbox name="variable_1" value="remained stable with no new complaints|remained stable and complained about discomfort due to stretcher, attempted to make pt comfortable by adjusting unit temperature, stretcher position, pt positioning, and emotional support|required medication changes to remain at found baseline, medication was titrated as documented and no ill effects where noted|stable but developed a complaint of -----|became unstable- DESCRIBE|OTHER"].[text name="variable_1" default="Does this call require more information????"] Pt [checkbox name="variable_1" value="was fairly talitive|was quiet but answers questions appropriately|was on their phone|was at known baseline with no change in activity|attempted to rest comfortably with their eyes closed, with consistent chest rise and fall, pt remained easily arousable|OTHER"].

On arrival to facility pt was transferred from stretcher to bed via  [checkbox name="variable_1" value="2 provider drawsheet|3+ provider drawsheet|assisted self scoot|assisted stand and pivot|assisted walk|unassisted walk|OTHER"] and made comfortable. [checkbox name="variable_1" value="Bedside report, paperwork, including any hard scripts, and care given to facility staff.|In hall report, paperwork, including any hard scripts, and care given to facility staff.|Pt left with facility staff at bedside.|Medications given to receicving facility.|Bed lowered to lowest position with rails raised and call bell within reach after pt was taught how to use it.|OTHER"]


Crew returned to service without incident. [checkbox name="variable_1" value="Pumps returned to sending facility."]

Signed by- 
Arrived to .
Got reprot from
Pt is going to for

Ambulance transport is medically necessary due to .

Patient specific orders from Dr. are
. Orders where . This medic requested orders for and where .

IV access remained clean dry and intact for duration of transport.

Pt is on baseline. O2 transferred between facility, stretcher, and onboard as appropriate without need for titration.

Crew Found pt .

Initial ABC's:

-Airway:

-Breathing:

-Circulation:


PHYSICAL EXAM:

General:


HEENT:


Nose:


Mouth:


Throat:


NECK:


Chest/Lungs:


Abdomen:


Neuro:



Pt was transferred to stretcher via and made comfortable and secured as appropriate.

Pumped medications where

Gravity medications

In unit pt was monitored as recorded and . Pt .

On arrival to facility pt was transferred from stretcher to bed via and made comfortable.


Crew returned to service without incident.

Signed by-

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.55, 47 form elements, 130 boilerplate words, 13 text boxes, 8 text areas, 23 checkboxes, 3 drop downs, 208 total clicks
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