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 [select name="Reason" 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. [textarea name="variable_1" default="sample text"] are [text 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"] at 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="set by sending facility and where not modified in anyway by crew|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 at 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 0.54, 46 form elements, 131 boilerplate words, 13 text boxes, 8 text areas, 21 checkboxes, 4 drop downs, 201 total clicks
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