PROTEK INTERFACILITY

TRANSPORT CREW LOCATED PT ROOM AND THE NURSE IN CHARGE OF PT. OBTAINED DISCHARGE DOCUMENTATION FOR TRANSPORT, VERIFIED DESTINATION, ESTABLISHED AT LOCATION PT CURRENT DIAGNOSIS OF [text name="admitdx" size = 30 default=" "].

CONSENT SIGNATURE FOR TRANSPORT: [checkbox name="SIGNATURE" value="OBTAINED FROM PATIENT|OBTAINED FROM GUARDIAN/POA|OBTAINED FROM RESPONSIBLE PARTY|NOT OBTAINED FROM PATIENT|UNABLE TO SIGN|LAW ENFORCEMENT SIGNED AS|NURSE SIGNED AS|EMS CREW SIGNED AS| REPRESENTATIVE|WITNESS|NO REPRESENTATIVE AVAILABLE"][text name="pe_signature" 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|BURN UNIT|CRITICAL CARE|NEPHROLOGY|IMAGING|GASTROENTEROLOGY"][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 ERECT UNASSISTED IN CHAIR OR WHEELCHAIR FOR A DURATION/ANY PART OF TRIP"]

PATIENT REQUIRED: [checkbox name="CARE" value="CARDIAC MONITORING|IV FLUID MANAGEMENT|IV PUMP MANAGEMENT|PAIN 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 ACLS DRUGS PRESENT DURING TRANSPORT"][text name="ros_heme" default=" "]

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


-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 BETWEEN 2-6 LITERS PER MINUTE|ON NON REBREATHER WITH OXYGEN BETWEEN 12-15 LITERS PER MINUTE|RECEIVING NEBULIZED BREATHING TREATMENT"][text name="airway" default=" "]

-BREATHING: [checkbox name="breathing" value="NORMAL BREATHING WITH ADEQUATE RATE AND TIDAL VOLUME|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|OBTUNDED|CHEMICALLY SEDATED|BASELINE FOR PT"][text name="consciousness" size = 55 default=" "]

-PSYCH: [checkbox name="ros_psych_check" value="PLEASANT, CALM, AND COOPERATIVE, JUDGEMENT AND INSIGHT INTACT, UNDERSTANDS TREATMENT, THOUGHT PROCESS IS LOGICAL/LINEAR AND AGE APPROPRIATE WITH NORMAL AFFECT|HAS A PLAN MADE|UNPLEASANT|NOT CALM|UNCOOPERATIVE|DOES NOT HAVE A PLAN|DOES NOT UNDERSTAND TREATMENT|IMPAIRED ATTENTION/CONCENTRATION|JUDGEMENT AND INSIGHT NOT INTACT|MOOD INSTABILITY|DENIES - SUICIDAL IDEATIONS, HOMICIDAL IDEATIONS, AUDITORY HALLUCINATIONS, VISUAL HALLUCINATIONS, DEPRESSION, OR MOOD CHANGES|AFFIRMS -|SUICIDAL IDEATIONS|HOMICIDAL IDEATIONS|AUDITORY HALLUCINATIONS|MOOD CHANGES|VISUAL HALLUCINATIONS|DISTRACTED|UNHAPPY|AGITATED|APATHY|ANXIOUS|WORRIES|DISSOCIATIVE|UPSET|TEARFUL|FEARFULNESS|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="ros_psych" default=" "]

MOBILITY: [checkbox name="pe_mobil1_check" value="PT ABLE TO AMBULATE TO STRETCHER|PT MOVED TO STRETCHER VIA DRAW-SHEET METHOD|PT PLACED ON STRETCHER USING LIFT & CARRY TECHNIQUES|PT PLACED ON STRETCHER USING SPINEBOARD|W/O ASSISTANCE|W/ ASSISTANCE|W/O INCIDENT OR PAIN EXPRESSION OR DISCOMFORT|W/ PAIN/DISCOMFORT EXPRESSED|SECURED PATIENT TO STRETCHER WITH 4 STRAPS AND 2 RAILS UPRIGHT|SUPINE POSITION|LOW FOWLER'S POSITION|SEMI-FOWLER'S POSITION|FOWLER'S POSITION|FULL FOWLER'S/SITTING POSITION|LOADED INTO AMBULANCE FOR TRANSPORT W/O INCIDENT"][text name="pe_mobil1" default=" "]

REVIEW OF SYSTEMS:

-CONSTITUTIONAL: [checkbox name="ros_constitutional_check" value="DENIES -|FEVER|CHILLS|WEAKNESS|FATIGUE|WEIGHT LOSS|AGE RELATED MUSCULAR ATROPHY|SENESCENCE|FRAILTY|AFFIRMS - |FEVER|CHILLS|WEAKNESS|FATIGUE|WEIGHT LOSS|FRAILTY|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="ros_constitutional" default=" "]

-HEET: [checkbox name="ros_heent_check" value="NORMOCEPHALIC, ATRAUMATIC, WHITE SCLERA, CONJUNCTIVA PINK/RED, EARS PATENT|EYES PERRLA|NORMAL MUCOUS|NO BLEEDING|NO TRAUMA TO FACE OR MOUTH|EYES NOT PERRLA|PUPILS DILATED|PUPILS CONSTRICTED|BLEEDING|DRY MUCOUS MEMBRANES|EXTRA SALIVATION|TRAUMA TO FACE|TRAUMA TO MOUTH|GLASSES|CONTACT LENS|DENIES - FACIAL PAIN, VISION CHANGES, EYE IRRITATION, EAR PAIN, NASAL CONGESTION|AFFIRMS -|VISION CHANGES|EYE IRRITATION|EAR PAIN|NASAL CONGESTION|FACIAL PAIN|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="ros_heent" default=" "]

-NECK: [checkbox name="ros_neck_check" value="SUPPLE NECK|NO NECK SWELLING/LUMPS|BLEEDING|TRAUMA TO NECK|NECK SWELLING/LUMPS|JUGULAR VEIN DISTENSION|TRACHEAL DEVIATION - LEFT|TRACHEAL DEVIATION - RIGHT|DENIES - SORE THROAT, NECK PAIN,THROAT CONGESTION OR COUGH|AFFIRMS -|SORE THROAT|THROAT CONGESTION|COUGH|NECK PAIN|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="ros_neck" default=" "]

-CHEST: [checkbox name="pe_chest_check" value="BILATERAL EQUAL RISE AND FALL|CONCAVE CHEST - NORMAL|BLEEDING|ATRAUMATIC|NO TENDERNESS|TENDERNESS|BARREL CHEST|CLEAR TO AUSCULTATION BILATERALLY UPPER/MIDDLE/LOWER LOBES|NO RALES, RHONCHI, WHEEZES, STRIDOR, PLEURAL RUB, RETRACTIONS, OR ACCESSORY MUSCLE USE|WHEEZING|RALES|RHONCHI
|STRIDOR|PLEURAL RUB|RETRACTIONS|UPPER RESPIRATORY CONGESTION|ACCESSORY MUSCLE USE|RIGHT UPPER LOBE|RIGHT MIDDLE LOBE|RIGHT LOWER LOBE|LEFT UPPER LOBE|LEFT LOWER LOBE|BILATERALLY|NO FLAIL SEGMENT|UNEQUAL CHEST RISE AND FALL|FLAIL SEGMENT|DENIES - SHORTNESS OF BREATH, HEMOPTYSIS, ORTHOPNEA, DYSPNEA ON EXERTION, DYSPNEA, CHEST PAIN OR DISCOMFORT, PALPITATIONS, OR SWELLING OF EXTREMITIES|AFFIRMS - |CHEST PAIN/DISCOMFORT|PALPITATIONS|SWELLING OF EXTREMITIES|SHORTNESS OF BREATH|DYSPNEA ON EXERTION|CHEST PAIN/DISCOMFORT|PALPITATIONS|HEMOPTYSIS|ORTHOPNEA|DYSPNEA|APNEIC|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="pe_chest" default=" "]

-GI: [checkbox name="ros_gi_check" value="ATRAUMATIC, NON-DISTENDED OR RIGID, NO GUARDING|BOWEL SOUNDS PRESENT IN ALL 4 QUADRANTS|ABDOMEN SOFT/NON-TENDER TO PALPATION, NO MASSES, NO REBOUND TENDERNESS|REBOUND TENDERNESS|TRAUMA PRESENT|TENDER ABDOMEN|RIGID ABDOMEN|DISTENDED ABDOMEN|GUARDING PRESENT|MASSES PRESENT|GENERALIZED|LEFT LOWER QUADRANT|LEFT UPPER QUADRANT|RIGHT LOWER QUADRANT|RIGHT UPPER QUADRANT|DENIES - N/V/D, CONSTIPATION, CHANGE IN APPETITE, DYSPHAGIA, ABDOMINAL PAIN, MELENA, HEMATOCHEZIA OR HEMATEMESIS|AFFIRMS -|CHANGE IN APPETITE|ABDOMINAL PAIN|HEMATEMESIS|MELENA|HEMATOCHEZIA|DYSPHAGIA| NAUSEA|VOMITING|DIARRHEA|CONSTIPATION|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="ros_gi" default=" "]

-GU: [checkbox name="ros_gu_check" value="STABLE GAIT|NO TENDERNESS|FECAL INCONTINENCE|DENIES - LEAKAGE OF URINE, DYSURIA, HEMATURIA, OLIGURIA, INCREASED URINARY FREQUENCY OR URGENCY|DENIES SEXUAL DYSFUNCTION|DENIES FECAL INCONTINENCE|AFFIRMS -|SEXUAL DYSFUNCTION|ABNORMAL GENITALIA DISCHARGE|INCREASED URINARY FREQUENCY|FOLEY PLACED|INCREASED URINARY URGENCY|DYSURIA|OLIGURIA|HEMATURIA|LEAKAGE OF URINE|PELVIC TENDERNESS|UNSTABLE GAIT|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="ros_gu" default=" "]

-MSK: [checkbox name="ros_msk_check" value="NORMAL RANGE OF MOTION|WITHOUT PAIN ON PALPATION|NO CREPITUS|NO OBVIOUS DEFORMITY|STRENGTH AGE APPROPRIATE|ABNORMAL RANGE OF MOTION|PAIN ON PALPATION|STRENGTH NOT PRESENT|CREPITUS|CONTRACTURES PRESENT|ASTHENIA|OBVIOUS DEFORMITY|IN ALL EXTREMITIES|LEFT UPPER EXTREMITY|RIGHT UPPER EXTREMITY|LEFT LOWER EXTREMITY|RIGHT LOWER EXTREMITY|DENIES - NECK PAIN, GENERALIZED JOINT PAIN, GENERALIZED MUSCLE ACHES/PAIN/CRAMPS/WEAKNESS|AFFIRMS -|NECK PAIN|GENERALIZED JOINT PAIN|GENERALIZED MUSCLE ACHES|GENERALIZED MUSCLE PAIN|GENERALIZED MUSCLE CRAMPS|GENERALIZED MUSCLE WEAKNESS|CONTRACTURES PRESENT|ASTHENIA|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="ros_msk" default=" "]

-BACK: [checkbox name="ros_back_check" value="UNREMARKABLE BACK INSPECTION|ABNORMAL BACK INSPECTION|FULL RANGE OF MOTION|ABNORMAL RANGE OF MOTION|DENIES - BACK PAIN, LOWER BACK PAIN/DORSALGIA/LUMBAGO|AFFIRMS -|UPPER BACK PAIN|MID BACK PAIN|LOWER BACK PAIN/DORSALGIA/LUMBAGO|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="ros_back" default=" "]

-SKIN: [checkbox name="ros_skin_check" value="NO RASHES, SKIN TEARS, SWELLING, LESIONS, OR DISCOLORATION|PINK, WARM, AND DRY, W/ GOOD TURGOR|PINK|DRY|PALE|COOL|CYANOTIC|FLUSHED|CLAMMY|HOT|WARM|DIAPHORETIC|LIVIDITY|MOTTLING|JAUNDICED|SKIN TEAR|SWELLING|POOR SKIN TURGOR|EXCESSIVELY DRY SKIN|DENIES - SKIN PAIN, NUMBNESS, TINGLING, DISCOLORATION, SWELLING, RASH, BRUISING, LESIONS, SKIN BREAKS, SENSITIVITY OR ITCHING|AFFIRMS -|RASH|BRUISING|LESIONS|SKIN PAIN|NUMBNESS|TINGLING|DISCOLORATION|SENSITIVITY|SWELLING|SKIN BREAKS|ITCHING|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE"][text name="ros_skin" default=" "]

-NEURO: [checkbox name="ros_neuro_check" value="GROSSLY ORIENTED X 4, GAIT STEADY & BALANCED, SENSATION INTACT WITH NORMAL REFLEXES, SMILE SYMMETRICAL, AND SPEECH NOT SLURRED|NEURO NOT GROSSLY INTACT|APHAGIA|APHASIA|DECEBERATE POSTURING|DECORTICATE POSTURING|SEIZURE ACTIVITY|STRENGTH ASYMMETRICAL|GAIT ABNORMAL|SENSATION ABSENT|NO REFLEXES|SMILE ASYMMETRICAL|HEMIPLEGIA|HEMIPARESIS|SLURRED SPEECH|OBTUNDED|DENIES - HEADACHE, DIZZINESS, SYNCOPE, NUMBNESS/TINGLING, SEIZURES OR OTHERWISE LOSS OF CONSCIOUSNESS|DENIES FOCAL DEFICITS|AFFIRMS -|FOCAL DEFICITS|INCOORDINATION|MEMORY DEFICITS|HEADACHE|DIZZINESS|OBTUNDED|SYNCOPE|NUMBNESS/TINGLING|LOSS OF CONSCIOUSNESS|DID NOT ASSESS|UNABLE TO ASSESS|UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE|UNABLE TO ASSESS TO DUE TO UNCOOPERATIVE STATE"][text name="ros_neuro" default=" "]
 
TREATMENT: [checkbox name="treatment" value="PRIMARY AND SECONDARY ALS ASSESSMENT|PRIMARY AND SECONDARY BLS ASSESSMENT|ISOLATION PRECAUTIONS"][textarea name="rxt" default=" "]

DURING TRANSPORT: [checkbox name="PRE_TRANS2" value="NO CHANGES, PT REMAINED UNCHANGED FROM INITIAL ASSESSMENT"] [textarea name="pe_trans3" default=" "]

AT DESTINATION: [checkbox name="pe_dest_check" value="PT ABLE TO AMBULATE FROM STRETCHER TO HOSPITAL BED|PT MOVED FROM STRETCHER TO HOSPITAL BED VIA DRAW-SHEET|PT MOVED FROM STRETCHER TO HOSPITAL BED VIA SPINEBOARD|W/O ASSISTANCE|W/ ASSISTANCE|W/O INCIDENT|IMPROVEMENT IN PATIENT CONDITION|DECLINE IN PATIENT CONDITION|NO CHANGE IN PATIENT CONDITION|PATIENT BELONGINGS LEFT WITH NURSE|VERBAL REPORT COMMUNICATED TO NURSE"][text name="pe_dest" default=" "]

PERSON RECEIVING PATIENT: [text name="PERS2" size = 55 default=" "],[checkbox name="PERS1" value="RN|LVN|CNA|NURSE|FAMILY|MPOA|POA|GUARDIAN|PARENT|LAW ENFORCEMENT"]

REPORT WRITER: [text name="WRITER" size = 55 default=" "] EOR