S.T.A.R. Ambulance Transfer PCR

DISPATCH: [checkbox name="DISPATCH" value="STAR M1 Non Emergent|STAR M5 Non Emergent|STAR M1 Emergent|STAR M5 Emergent"][textarea name="dispatch" default=" "]

ARRIVED: [checkbox name="ARRIVED" value="Hendricks Danville|Hendricks Brownsburg|Franciscan Crawfordsville|IU Methodist|Ben Hur|Wellbrook of Crawfordsville|Lane House| Bickford of Crawfordsville|Patients Residence"][textarea name="variable_1" default=""]

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

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=" "]

INITIAL ABC's:
-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=" "]


-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=" "]

INITIAL PHYSICAL ASSESSMENT:

-GENERAL: [checkbox name="pe_general_check" value="In no acute distress|Malnourished|In mild distress|In Severe distress"][text name="pe_general" 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|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=" "]

-SKIN: [checkbox name="pe_skin_check" value="Pink, Warm, and Dry|Pale|Cool|Cyanotic|Flushed|Clammy|Hot|diaphoretic|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=" "]


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="STEMI Alert|Stroke Alert|Trauma Alert|No alerts activated "][text name="pe_act" default=" "]

TRANSPORT: [checkbox name="pe_trans_check" value="Secured patient to stretcher with straps and rails upright|Loaded into ambulance for transport|Emergenct|Non-emergent|Non-emergent upgraded to emergent| Hendricks Danville| IU Methodist| Franciscan East| Francsican South|St. Vincent 86th St.| Eskenazi Health"][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 Family Member|Obtained From Nurse|Transfer of Care signed"][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="Cameron Townsend EMT-P 6502-1274|Madison Townsend EMT-B 2345-0692"][text name="RW" default=" "]