Pilcher’s Transfer

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|Pre-scheduled emergency|Pre-scheduled non-emergency transport|Helipad transport|Airport transport|NICU transport"][textarea name="dispatch" default=" "]

ARRIVED: [textarea name="arrived" default=" "]

INTER-FACILITY TRANSFER FOR FOLLOWING REASON: [checkbox name="TRANSFER" value="Services not available at present facility in|Higher level of care in|Cardiology|Neurology|Surgery|Behavioral medicine|OBGYN|Stroke|Trauma|Rehabilitation|Burn unit|Critical care|Orthopedics|Pediatrics|Vascular|Dialysis transport|Woundcare transport|Discharge transport"][text name="TRANSFER" default=" "]

PATIENT CRITICALLY ILL: [checkbox name="CCT" value="YES|NO"]

PATIENT BEDBOUND PER MEDICARE DEFINITION (MUST MEET ALL 3 REQUIREMENTS): [checkbox name="BEDBOUND" value="Yes|No|Cannot transfer from bed without assistance|Non-ambulatory without assistance|Cannot sit upright unassisted"]

PATIENT REQUIRED: [checkbox name="CARE" value="Transport services only|Hemodynamic monitoring|Cardiac monitoring|IV fluid management|IV pump management|Oxygen enroute|Airway management|Nebulized treatment during transport|Special orthopedic handling (backboard, halo traction, non-weight bearing, pins and traction)|Behavioral monitoring|Special positioning for|Decubitus on buttocks|Contractures|Recent extremity fracture|Post surgery|Currently intubated|Possible intubation during transport|Vent dependent|Apnea monitoring|Suctioning during transport|Isolation precautions|Chest tube|Physician request for ALS drugs present during transport "][text name="ros_heme" default=" "]

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

Hx:
Onset: [text name="O" size = 55 default=" "]
Other PERTINENT Hx: [textarea name="hpi" 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" value="NKDA"][textarea name="allergies" default=" "]

INITIAL ABC's:
-AIRWAY: [checkbox name="airway" value="Normal airway open, patent, and without obstructions|Patient on CPAP|Patient intubated and on ventilator|Secretions in endotracheal tube requiring suction|On nasal cannula with oxygen at ? LPM|On non-rebreather with oxygen at ? LPM|Receiving nebulized breathing treatment"][text name="airway" default=" "]
-BREATHING: [checkbox name="breathing" value="Normal breathing with adequate rate and normal chest expansion|Breathing rate and volume controlled by ventilator"][text name="breathing" default=" "]
-CIRCULATION: [checkbox name="circulation" value="Normal, pulses intact, skin color and temperature appropriate|Without presence of obvious life threats to circulation|Hemorrhage present but controlled by prior interventions|Pulses not intact as noted|Skin color and temperature 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|Chemically sedated"][text name="consciousness" size = 55 default=" "]

TREATMENT: [checkbox name="treatment" value="Primary and secondary ALS assessment|Primary and secondary BLS assessment|Continuous cardiac monitoring|Care provided and maintained by CCT"] [textarea name="rxt" default=" "]

TRANSPORT: [checkbox name="pe_trans_check" value="Secured patient to stretcher with 3 straps and rails upright|Helicopter sled secured to stretcher|Airplane sled secured to stretcher|NICU stretcher|Loaded into ambulance for transport|Emergency|Non-emergency|Transported to Flowers Hospital|Transported to Southeast Health|Transported to UAB|Transported to Children’s Hospital of Alabama|Transported to Sacred Heart|Transported to Austel|Transported to Emory University Hospital|Transported to Shands Hospital|Transported to University of South Alabama Hospital|Transported to BayPointe Hospital|Transported to Encompass Health|Transported to Westside Terrace |Transported to    Grand South Assisted Living|Transported to Wesley Place|Transported to ExtendiCare|Transported to Enterprise Health and Rehab|Transported to Oakview Manor|Transported to Ozark Health and Rehab|Transported to Henry Co. Health and Rehab|Transported to Signiture Health of North Florida|Transported to Signiture Healthcare at the Courtyard|Transported to Crowne Healthcare|Transported to Hartford Healthcare|Transported to Troy Health and Rehab|Transported to Laurel Oaks|Transported to Beacon Health Hospital|Transported to DCI |Transported to Davita Dothan|Transported to Wiregrass Davita|Transported to SEH Woundcare|Transported to Flowers Hospital Woundcare|Transported to Residence|Transported to SEH Helipad|Transported to Dothan Airport"][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|Obtained from guardian/POA|Obtained from family|Not obtained from patient|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|Receiving signature obtained from family"][text name="pe_SIG" default=" "]


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, NRP 2200523|Craig Gaff, EMT-I 9701184|Kevin Stewart, NRP 1800901|Taylor Robison, NRP 1300242|Ashlee Clevenger, AEMT 2300102"][text name="RW" default=" "]