Incident/Dispatch:[textarea name="incident" default=" "]
Upon Arrival: [textarea name="UA" default=" "]

Age/Gender: [text name="agegender" default=""]
History of Present Issue: [textarea name="HPI" default=" "]
Hx: PMH, Rx, Allergies Noted in PCR- [textarea name="e" size = 55 default=" "]
Other Hx Info: [textarea name="otherhx" default=" N/A."]
Social History: [checkbox name="SocialHistory" value="Denies drug use|Denies ETOH use|Does not smoke cigarettes|Endorses ETOH use|Endorses recreational drug use|Cigarette smoker|Former cigarette cmoker|Substance abuse in recovery|Not obtained"]. [textarea name="socdetails" size = 15 default=" "]

Review of Systems:
HEENT: [checkbox name="HEENT" value="No reported changes in vision|No reported changes in hearing|No reported symptoms of upper respiratory tract infection|Unable to assess"]. [textarea name="HEENT" default=""]
CNS: [checkbox name="CNS" value="CMS grossly intact in all 4 extremities|No reported headache|No reported neurologic symptoms|Unable to assess"]. [textarea name="CNS" default=""]
PSYCH: [checkbox name="psych" value="No reported recent or active suicidality|No reported recent or active homicidal ideations|No reported recent or active visual/auditory disturbances|Unable to assess"]. [textarea name="psych" default="]
CARDIOVASCULAR: [checkbox name="cardio" value="No reported palpitations|No reported chest pain or discomfort|Reports palpitations|Reports chest pain|Unable to assess"]. [textarea name="cardiovascular" default=""]
PULMONARY: [checkbox name="pulm" value="No reported SOB|No reported cough|SOB reported|Cough reported|Unable to assess"]. [textarea name="PULM" default=""]
GI/GU: [checkbox name="gigu" value="No reported nausea|No reported vomiting|No changes in bowel reported|No change in urine reported|Nausea reported|Vomiting reported|Unable to assess"].  [textarea name="GIGU" default=""]
MUSCULOSKELETAL: [checkbox name="musk" value="No reported musculoskeletal pain or injuries|Unable to assess"].  [textarea name="msk" default=""]
[checkbox name="OBGYN" value="OBGYN:"][conditional field="OBGYN" condition="(OBGYN).is('OBGYN:')"] [select name="OB" value=" |Denies possibility of pregnancy.|Endorses possibility of pregancy.|Pregnant.|Post-menopausal."] [textarea name="OB" default=""]

Physical Exam:
GENERAL: [checkbox name="general" value="GCS 15|Interacting with EMS appropriately|Not acutely distressed|Gait is steady|Speech is not slurred|Does not interact well|Distressed|Confused|Gait is unsteady|Speech is slurred|Unresponsive|Unable to assess"]. [textarea name="general" default=""]
HEAD: [checkbox name="head" value="No noted trauma|Pupils equally round and reactive to light|No facial droop|Mucous membranes are moist"]. [textarea name="head" default=""]
NECK: [checkbox name="neck" value="No noted trauma|No JVD|No midline pain"]. [textarea name="NECK" default=""]
CHEST: [checkbox name="chest" value="No noted trauma|Equal rise and fall|Normal and adequate tidal volume and respiratory drive|Breath sounds CTA bilaterally"]. [textarea name="chest" default=""]
BACK: [textarea name="back" default=" No noted trauma. "]
ABDOMEN: [checkbox name="abd" value="No noted trauma|Soft, flat, non-tender on palpation"]. [textarea name="abd" default=""]
PELVIS: [checkbox name="pelvis" value="No noted trauma|Stable"]. [textarea name="pelvis" default=""]
EXTREMITIES: [checkbox name="extremities" value="No noted trauma|No clubbing, cyanosis, or edema"]. [textarea name="extremities" default=""]
SKIN: [checkbox name="skin" value="Normal tone, warm, dry|Pale|Cool|Hot|Diaphoretic|Normal tone|Warm|Dry"]. [textarea name=""]
VITALS: [select name="vital" value="Stable as noted. | "][textarea name="vitals" default=" "] [comment memo="BGL IF OBTAINED"][select name="glucose" value=" |Hypoglycemic. |BGL Normal. | Hyperglycemic. "]
[comment memo="EKG IF OBTAINED"][select name="EKG" value=" | 12 lead EKG:|4 lead EKG: "][textarea name="ekginterpretation" default=" "]
Additional Findings: [textarea name="additional" default=" N/A"]
[checkbox name="IMC-RASS" value="IMC-RASS:"][conditional field="IMC-RASS" condition="(IMC-RASS).is('IMC-RASS:')"]
[checkbox name="IMCRASSSCORE" value="-5 Unarousable| -4 Deep Sedation| -3 Moderate Sedation| -2 Light Sedation| -1 Drowsy| 0 Alert and Calm| +1 Restless| +2 Agitated but redirectable| +3 Agitated, routine care impossible| +4 Combative and Violent"]
[checkbox name="NIH" value="---NIH STROKE SCALE---"][conditional field="NIH" condition="(NIH).is('---NIH STROKE SCALE---')"] 
#1a. Level of Consciousness --> [select name="conscious"  value="Alert (0 points)=0|Arousable by minor stimulation (1 point)=1|Requires repeated stimulation to arouse (2 points)=2|Not responsive (3 points)=3"]
#1b. Orientation: Month, Age --> [select name="orientation"  value="Answers both questions correctly (0 points)=0|Answers one question correctly (1 point)=1|Answers neither question correctly (2 points)=2"]
#1c. Blink eyes & Squeeze Hands -->[select name="commands"  value="Performs both tasks correctly (0 points)=0|Performs one task correctly (1 point)=1|Performs neither task correctly (2 points)=2"]
#2. Horizontal extraocular movements--> [select name="finger"  value="Normal (0 points)=0|Partial gaze palsy (1 point)=1|Forced deviation (2 points)=2"]
#3. Visual fields--> [select name="visual"  value="No visual loss (0 points)=0|Partial hemianopia (1 point)=1|Complete hemianopia (2 points)=2|Bilateral loss (3 points)=3"]
#4. Facial palsy--> [select name="face"  value="Normal (0 points)=0|Minor paralysis (1 point)=1|Partial paralysis (2 points)=2|Complete paralysis (3 points)=3"]
#5a. Motor Strength Left Arm--> [select name="left_arm"  value="No drift (0 points)=0|Drift (1 point)=1|Some effort against gravity (2 points)=2|No effort against gravity (3 points)=3|No movement (4 points)=4|Amputation or joint fusion (0 points)=0"]
#5b. Motor Strength Right Arm--> [select name="right_arm"  value="No drift (0 points)=0|Drift (1 point)=1|Some effort against gravity (2 points)=2|No effort against gravity (3 points)=3|No movement (4 points)=4|Amputation or joint fusion (0 points)=0"]
#6a. Motor Strength Left Leg--> [select name="left_leg"  value="No drift (0 points)=0|Drift (1 point)=1|Some effort against gravity (2 points)=2|No effort against gravity (3 points)=3|No movement (4 points)=4|Amputation or joint fusion (0 points)=0"]
#6b. Motor Strength Right Leg--> [select name="right_leg"  value="No drift (0 points)=0|Drift (1 point)=1|Some effort against gravity (2 points)=2|No effort against gravity (3 points)=3|No movement (4 points)=4|Amputation or joint fusion (0 points)=0"]
#7. Limb ataxia--> [select name="ataxia"  value="Absent (0 points)=0|Ataxia in one limb (1 point)=1|Ataxia in two limbs (2 points)=2"]
#8. Sensation--> [select name="sensory"  value="Normal (0 points)=0|Mild to moderate loss (1 point)=1|Severe to total loss/unresponsive (2 points)=2"]
#9. Language (Comprehension/expression)-->  [select name="language"  value="No aphasia, normal comprehension/expression (0 points)=0|Mild to moderate aphasia (1 point)=1|Severe aphasia (2 points)=2|Mute, global aphasia/unresponsive (3 points)=3"]
#10. Dysarthria--> [select name="dysarthria"  value="Normal, easily understood (0 points)=0|Mild to moderate dysarthria (1 point)=1|Severe dysarthria (2 points)=2|Intubated or physical barrier (0 points)=0"]
#11. Extinction and Inattention--> [select name="extinction"  value="No abnormality (0 points)=0|Visual, tactile, auditory, spatial, or personal inattention in one sensory modality (1 point)=1|Profound hemi-inattention or extinction to more than one modality (2 points)=2|Inattention to bilateral stimuli (1 point)=1"]
-----> [calc value="(conscious)+(orientation)+(commands)+(finger)+(visual)+(face)+(left_arm)+(right_arm)+(left_leg)+(right_leg)+(ataxia)+(sensory)+(language)+(dysarthria)+(extinction)" memo="score"] <-----

Impression(s): [textarea name="impression" default=" "]

Course of Treatment: 
[checkbox name="treat" value="No immediate treatment required|Cervical Collar applied|IV established"]. [textarea name="treatment" default=" "]

Moved to ambulance via [select name="moved" value=" | 1-2 person assisted walk to stretcher. |Walked to Stretcher. |Stairchair to stretcher. | Carried to stretcher. | Walked to seat in ambulance. "][textarea name="movedother" default="Appropriately and safely secured."]
Transport [select name="urgency" value="Non-emergent |Emergent | Upgraded to emergent "]to [select name="destination" value=" |NSMC |Lutheran |St. Anthony 84th |Denver Health |St. Anthony North |ED |  "]with pre-arrival [select name="callin" value="Notification |Trauma Alert |Stroke Alert |Cardiac Alert |  "]made enroute. [textarea name="trnspt" default=" During transport patient remains stable. "]

Hospital Arrival:
[textarea name="hosp" default=" Upon arrival at ED handoff given to nurse and provider at bedside. Nurse signs PCR. "][select name="ptsign" value="Patient signs PCR. |Patient unable to sign PCR. |Equipment failure/malfunction prevented signature. |Patient refused to sign PCR. "][text name="signdetails" default=""]

No further care.
-[comment memo="Provider Name:"] [text name="providername" default=""]

[checkbox name="Student" value="*Some assessments and procedures were performed by paramedic student who was under my direct supervision as the attending paramedic, and consistent with student's scope of practice.*"]
[checkbox name="Disclaimer" value="*Please note that this dictation was completed with computer voice recognition software. Oftentimes unanticipated grammatical, syntax, homophones, and other interpretive errors are inadvertently transcribed by the computer software. Please disregard these errors. Please excuse any errors that have escaped final proofreading.*"]

Upon Arrival:

History of Present Issue:

Hx: PMH, Rx, Allergies Noted in PCR-

Other Hx Info:

Social History: .

Review of Systems:

CNS: .




GI/GU: .


Physical Exam:










Additional Findings:


Course of Treatment:

Moved to ambulance via

Transport to with pre-arrival made enroute.

Hospital Arrival:

No further care.
-Provider Name:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.58, 88 form elements, 58 boilerplate words, 3 text boxes, 31 text areas, 23 checkboxes, 24 drop downs, 3 comments, 1 calculations, 3 conditionals, 153 total clicks
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