Pilcher’s 911

DISPATCH: [checkbox name="DISPATCH" value="Pilcher's 38-M1|Pilcher's 38-M2|Pilcher's 38-M3|Pilcher's 38-M4|Pilcher's 38-M5|Pilcher's 38-M6|Pilcher's 38-M7|Pilcher's 38-M8|Pilcher's 38-M9|Pilcher's 38-M10|Pilcher's 38-M12|Pilcher's 38-M14|Pilcher's 38-M15|Pilcher's 38-M16|Pilcher's 38-M17|Pilcher's 38-M25|E911 City Emergency with lights and sirens|E911 City Non-emergency without lights and sirens|E911 County Emergency with lights and sirens |E911 County Non-emergency without lights and sirens|Private 911 Emergency with lights and sirens|Private 911 Non-emergency without lights and sirens"][textarea name="dispatch" default=" "]

ARRIVED: [textarea name="arrived" default=" "][checkbox name="ARRIVED" value="DFD Engine 1 on scene with patient|DFD Engine 2 on scene with patient|DFD Engine 3 on scene with patient|DFD Engine 4 on scene with patient|DFD Engine 5 on scene with patient|DFD Engine 6 on scene with patient|DFD Engine 8 on scene with patient|DFD Engine 9 on scene with patient"]

CC: [text name="CC" default=" "]

Onset: [text name="O" size = 55 default=" "]
Provoking/Relieving Factors: [text name="P" size = 55 default=" "]
Quality/Described As: [text name="q" size = 55 default=" "]
Radiation: [text name="r" size = 55 default=" "]
Severity: [text name="s" size = 55 default=" "]
Events Surrounding Condition: [textarea name="e" size = 55 default=" "]

PMHx: [checkbox name="pmhx" value="None|Unable to obtain"][textarea name="pmhx" default=" "]

MEDICATIONS: [checkbox name="meds" value="None|Unable to obtain"][textarea name="medications" default=" "]

ALLERGIES: [checkbox name="allergies_check" value="NKDA"][textarea name="allergies" default=" "]

-AIRWAY: [checkbox name="airway" value="Normal|Airway open|Airway patent|No airway obstructions|Airway positioned to open|Airway not patent|Obstructions to airway|Requires airway adjunct|Requires advanced airway|Requires artificial ventilation"][text name="airway" default=" "]
-BREATHING: [checkbox name="breathing" value="Normal|Breathing spontaneously|Breathing regular|Adequate respirations|Chest expansion normal|Labored breathing|Not spontaneously breathing|Irregular respirations|Inadequate respirations|Inadequate tidal volume"][text name="breathing" default=" "]
-CIRCULATION: [checkbox name="circulation" value="Normal|No Obvious Bleeding|Pulses Intact|Skin Color Appropriate|No Life Threats To Circulation|Hemorrhage Present|Hemorrhage Controlled|Arterial Tourniquet Applied|Pulses Not Intact|Skin Color Not Appropriate|Life Threatening Concerns With Circulation"][text name="ros_constitutional" default=" "]
-LEVEL OF CONSCIOUSNESS: [checkbox name="loc" value="Alert|Oriented|Person|Place|Time|Event|Disoriented|Arousable By Verbal Stimuli|Arousable By Painful Stimuli|Unresponsive"][text name="consciousness" size = 55 default=" "]

-BLOOD PRESSURE: [text name="pe_bp" default=" "]
-PULSE: [text name="pe_pulse" default=" "]
-RESP: [text name="Resp" default=" "]
-SPO2: [text name="pe_spo2" default=" "]
-BGL: [text name="pe_bgl" default=" "]
-TEMP: [text name="TEMP" default=" "]
-CO2: [text name="CO2" default=" "]
-EKG FINDINGS: [checkbox name="EKG" value="4 Lead ECG obtained|12 Lead ECG obtained|By PAS medic|By PAS crew member|By DFD medic|Manual interpretation|Computer interpritation|STEMI|Sinus Rhythm|Paced Rhythm|Sinus Bradycardia|Sinus Tachycardia|Sinus Arrhythmia|Wandering Atrial Pacemaker|Multifocal Atrial Tachycardia|A-Fib|A-Fib w/ RVR|Supraventricular Tachycardia|Atrial Flutter|Junctional Rhythm|First Degree AV Block|Second Degree Type 1|Second Degree Type 2|3rd Degree Block|IVR|Accelerated IVR|V-Tach|V-Fib|Asystole|PEA|Torsades|w/ PVC's|w/ PAC's|w/ PJC's "][text name="ros_heme" default=" "]

-GENERAL: [checkbox name="pe_general_check" value="Well developed, well nourished, and well appearing|In no acute distress|Malnourished|In mild distress|In acute distress|Obese "][text name="pe_general" default=" "]
-HEENT: [checkbox name="pe_heent_check" value="Normocephalic, Atraumatic, PERRLA, White sclera, Conjunctiva pink/red, Ears patent, Normal mucous and pharynx|No bleeding, trauma to face or mouth|Bleeding|Positive halo test|Negative halo test|Dry mucous membranes|Extra salivation|Trauma to face|Trauma to mouth "][text name="pe_heent" default=" "]
-CARDIOVASCULAR: [checkbox name="pe_cardio_check" value="Regular rate and rhythm, without jugular vein distention, or edema|Peripheral pulses intact, without cyanosis|Irregular rate|Irregular rhythm|ST elevation present|JVD present|Edema present|No peripheral pulses|Cyanosis present|Bleeding "][text name="pe_cardio" default=" "]
-RESPIRATORY: [checkbox name="pe_resp_check" value="Clear to auscultation bilaterally, no rales, rhonchi, wheezes, stridor, retractions, or accessory muscle use|Wheezing|Rales|Rhonchi|Stridor|Upper respiratory congestion|Non-productive cough|Productive cough "][text name="pe_resp" default=" "]
-GI: [checkbox name="pe_gi_check" value="Atraumatic, bowel sounds present in all 4 quadrants, abdomen soft/non-tender to palpation|Non-distended or rigid, no guarding, no masses|Trauma present|Tender abdomen|Rigid abdomen|Distended abdomen|Guarding present|Masses present "][text name="pe_gi" default=" "]
-MSK: [checkbox name="pe_msk_check" value="Normal range of motion, without pain on palpation, and strength 5/5 in all extremities|Abnormal range of motion|Pain on palpation|Strength not present in all extremities|Unable to assess"][text name="pe_msk" default=" "]
-SKIN: [checkbox name="pe_skin_check" value="No rashes, lesions, discoloration, pink, warm, and dry|Pale|Cool|Cyanotic|Flushed|Clammy|Hot|Jaundiced"][text name="pe_skin" default=" "]
-NEURO: [checkbox name="pe_neuro_check" value="Oriented x 4, gait normal, sensation intact with normal reflexes, smile normal, and speech not slurred|Neuro not intact|Gait abnormal|Sensation absent|No reflexes|Smile not symmetrical|Slurred speech|Unable to assess "][text name="pe_neuro" default=" "]
-PSYCH: [checkbox name="pe_psych_check" value="Pleasant, calm, and cooperative, judgement and insight intact, understands treatment, thought process in normal with normal effect|Has a plan made|Unpleasant|Not calm|Uncooperative|Does not have a plan|Does not understand treatment|Unable to assess "][text name="pe_psych" default=" "]
-HEMATOLOGIC: [checkbox name="pe_heme_check" value="No tenderness or masses palpated, no bruises or bleeding|Tenderness|Bruising|Bleeding|Unable to assess "][text name="pe_heme" default=" "]
-EMSA Stroke Assessment: [checkbox name="pe_emsa_check" value="Horizontal gaze normal|Face normal|Arm strength normal|Leg strength normal|Speech normal|Negative EMSA Stroke Assessment|Horizontal gaze abnormal| Facial droop noted| Arm strength abnormal| Leg strength abnormal| Speech Abnormal|Positive EMSA Stroke Assessment|EMSA Stroke Assessment Non-conclusive"][text name="pe_emsa" default=" "]

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="ATCC contacted for stroke|ATCC contacted for trauma|Thrombolytic checklist completed|Historian information and contact number gathered|STEMI Alert called to receiving facility|CPR in progress called to receiving facility|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|Non-emergency upgraded to emergency|Patient refused transport|AMA|Patient treated and released|No transport|Lift assist only|Transported to Flowers Hospital|Transported to Southeast Health|Transported to Dale Medical Center|per patient request|per family request|per PAS crew member discretion as closest facility|per ATCC recommendation"][text name="pe_trans" default=" "]

REPORT: [checkbox name="pe_rep_check" value="Verbal report to nurse|Patient belongings left with nurse|Patient belongings left with patient/family|Improvement in patient condition|Decline in patient condition|No change in patient condition "][text name="pe_rep" default=" "]

SIGNATURES: [checkbox name="SIGNATURE" value="Obtained from patient|Not obtained from patient|Obtained from guardian/POA|Obtained from family|Signed by law enforcement as guardian|Patient unable to sign due to (SPECIFY REASON WHY PT CAN'T SIGN)|No representative available|PAS crew member signed for patient|Nurse signed as witness|Receiving facility signature obtained from nurse"][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. "]

REPORT WRITER: [checkbox name="pe_RW_check" value="David Smith, NRP 1600562|Michael Jagannath, NRP 1001374|Daniel Grondin, AEMT 1900586|Timothy Smith, AEMT 0300996|Nickolas McIntyre, AEMT 2200523|Craig Gaff, EMT-I 9701184|Gabriel Ramirez, EMT-B 2200717|Ashlee Clevenger, AEMT 2300102"][text name="RW" default=" "]



Provoking/Relieving Factors:
Quality/Described As:
Events Surrounding Condition:






-EMSA Stroke Assessment:







Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.41, 69 form elements, 64 boilerplate words, 34 text boxes, 7 text areas, 28 checkboxes, 291 total clicks
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