TMA Transport

Date of Transport: [date name="date" default="today"]

RESPONSE:
Trans-Med Distpach, distpached Ambulance [text name="ambulance" default=""] responded to [text name="Responedto" default=""] for a general transport. 
Upon arrival, EMS found the patient [textarea name="foundpatient" default=""]. 
-The general impression of the patient was [textarea name="patientwas" default="how do you feel the pt is? -no distress, anxious, calm, sick, frail, ready for transport, etc "] 

[HISTORY OF PRESENT ILLNESS] 
Pt is being transported to [text name="destination" default="destination"] due to [textarea name="reasonfortransport" default="reason for transport -test/procedure,appointment, discharge, etc"] 
-Pt was admitted on and treated for [textarea name="whytheyarethere" default="admission diagnosis and any other issues treated"]
-History was obtained from [checkbox name="history" value="facesheet|patient|family|staff"]
-This problem began [text name="problembegain" default="state when they started with this issue. -Hours, days, weeks, months, years"]. 
-This is [select name="commonproblem" value="(chronic|an occasional|common|rare"] problem for the patient. 
-Primary Admission: [textarea name="Primary" default="If the pt was admitted, list the main reason for admission and any secondary reasons -Flu, Gl Bleed, pneumonia, stroke, etc."]
-Secondary Admission: [textarea name="secondary" default="Weakness, unsteady gait, etc due to the initial reason"] 
-The patient has the following medical history: [textarea name="Medicalhistory" default=""]

ASSESSMENT - PRIMARY: 
EMS performed a complete head to toe [select name="emsassessment" value="BLS|IALS|ALS"] assessment on the patient. 
-Patient is  [checkbox name="patientis" value="conscious|alert and oriented| lethargic| unresponsive| Altered| confused| uncooperative| anxious|disoriented"]
-This is [select name="normal" value="normal|abnormal)"] for the patient. 
[AIRWAY]: Patient's airway is [checkbox name="airway" value="patent| clear| noisey| with secretions"] 
[text name="airwayetc" default=""] [text name="ifonoxygen" default="if on oxygen NC on LPM"]
[VERBAL]: Speech: [checkbox name="verbal" value="(normal| slurred| garbled| nonverbal| not making sense"] 
[EYES] [select name="eyes" value="open|closed| looking around"] 
[CHEST]: [text name="Chest" default="Normal for patient"] 
[ABDOMEN]: [checkbox name="Abdomen" value="Normal for Patient| soft |hard |flat| round| thin |obese |distended| painful"] 
[EXTREMITIES]: [textarea name="Extremities" default="describe grasps, pulse, movement ability, sensation, or any lack of ability"]. 
[MUSCULOSKELETAL]: [textarea name="musculloskeletal" default="equal/unequal, normal, weak against gravity, slow/uncoordinated, list anything abnormal, wounds, splints, contracted"] 
[GAIT]: Patient mombility is [select name="Gait" value="can pt stand on own| with assistance| shuffles| with walker| not at all| bed-confined"] [text name="gaitetc" default=""]
[PAIN]: Patient states pain is [text name="Whereispain" default="where is the pain"] is rated [select name="painscale" value="0|1|2|3|4|6|7|8|9|10"] on a 0-10 scale. 
Patient was placed onto stretcher and secured for transport with 5 straps. Patient was positioned on stretcher in [select name="Postionofpt" value="semi-fowlers| fowlers| supine| lateral"]

[TREATMENT]:
[textarea name="Treatment" default="(did you provide any treatment to the patient? If so, list what you did. Ex, applied 02 due to low pulse ox, suctioned airway due to secretions) 
"]
[ASSESSMENT - SECONDARY]:
An ongoing assessment was performed throughout ems care. 

[TRANSPORT]:
[textarea name="Transport" default="Patient remain stable for the duration of the transport. "]
Reason for ambulance: [checkbox name="reasonforambulance" value="The patient is unable to get up from bed without assistance| The Patient is unable to ambulate| The patient is unable to sit in a chair or wheelchair or maintain a sitting posture|Requires restraints to prevent harm and or injury to self or others| Requires cardiac/hemodynamic monitoring en route| Requires continuous IV therapy en route| Requires advanced airway management| Must remain immobile because of a fracture or possibility of fracture| Requires continuous oxygen monitoring by trained medical personnel"]

[DESTINATION]:
-Patient was transported without incident to ([var name="destination"] and [textarea name="room" default="department/room"]. 
-Patient moved to [var name="room"] on stretcher and [checkbox name="transferfromstrecher" value="transferred to hospital bed by sheet lift|Patient reamin on stretcher for the duration of the transport|Patient was trasfered to procedure table and ems remain on location to return the patient"]. 
-All of patient's belongings were [text name="belongings" default="left with patient"]. 
-Patient care and report given to [text name="tansferofcare" default="RN"]. 
-Transport signature received from [select name="Signature" value="Patient|Authorized Rep|EMS"]
[conditional field="Signature" condition="(Signature).is('Authorized Rep')"]
Reason why patient did not sign: [checkbox name="Whynopt" value="patient is a Minor| Patient is unconscious| Patient is mentally incapacitated| Patient under the influence of drugs or alcohol|Patient is restrained and unable to sign| Patient is in great pain| patient is to weak"]
[text name="AR" default=""][/conditional]

[conditional field="Signature" condition="(Signature).is('EMS')"]
Reason why patient did not sign: [checkbox name="Whynopt" value="patient is a Minor| Patient is unconscious| Patient is mentally incapacitated| Patient under the influence of drugs or alcohol|Patient is restrained and unable to sign| Patient is in great pain| Patient is to weak"]
[textarea name="EMSs" default=""][/conditional]

[conditional field="transferfromstrecher" condition="(transferfromstrecher).isNot('transferred to hospital bed by sheet lift')"]
EMS Remain on location to return the patient.[/conditional]


Name: [text name="rw" default=""]
Cert: [text name="rwcert" default=""]
[date name="date2" default="timestamp"]


[conditional field="transferfromstrecher" condition="(transferfromstrecher).isNot('transferred to hospital bed by sheet lift')"][comment memo="Return trip Below" memo_color="red" memo_size="large" memo_style="bold"]

Ambulance [var name="ambulance"] was on loaction at [var name="destination" when staff stated that the patient was ready to be return to [var name="Responedto"] 
Upon arrival, EMS found the patient [var name="room"]. 
-The general impression of the patient was [textarea name="patientwasR" default="how do you feel the pt is? -no distress, anxious, calm, sick, frail, ready for transport, etc "] 

[HISTORY OF PRESENT ILLNESS] 
Pt is being transported to [var name="Responedto"]after [var name="reasonfortransport"]  
-Pt was admitted on and treated for [var name="whytheyarethere"]
-History was obtained from [var name="history"]
-This problem began [var name="problembegain"]. 
-This is [var name="commonproblem"] problem for the patient. 
-Primary Admission: [var name="Primary"]
-Secondary Admission: [var name="secondary"]
-The patient has the following medical history: [var name="Medicalhistory"]

ASSESSMENT - PRIMARY: 
EMS performed a complete head to toe [var name="emsassessment"] assessment on the patient. 
-Patient is  [var name="patientis"]
-This is [var name="normal"] for the patient. 
[AIRWAY]: Patient's airway is [var name="airway"] 
[var name="airwayetc"] [var name="ifonoxygen"]
[VERBAL]: Speech: [var name="verbal"] 
[EYES] [var name="eyes"] 
[CHEST]: [var name="Chest"] 
[ABDOMEN]: [var name="Abdomen" ] 
[EXTREMITIES]: [var name="Extremities" ].
[MUSCULOSKELETAL]: [var name="musculloskeletal" ] 
[GAIT]: Patient mombility is [var name="Gait"] [var name="gaitetc"]
[PAIN]: Patient states pain is [var name="Whereispain"] is rated [var name="painscale" ] on a 0-10 scale. 
Patient on the stretcher and secured for transport with 5 straps. Patient was positioned on stretcher in [var name="Postionofpt"]

[TREATMENT]:
[textarea name="TreatmentR" default="(did you provide any treatment to the patient? If so, list what you did. Ex, applied 02 due to low pulse ox, suctioned airway due to secretions) 
"]
[ASSESSMENT - SECONDARY]:
An ongoing assessment was performed throughout ems care. 

[TRANSPORT]:
[textarea name="TransportR" default="Patient remain stable for the duration of the transport. "]
Reason for ambulance: [var name="reasonforambulance"]

[DESTINATION]:
-Patient was transported without incident to [var name="Responedto"] and [textarea name="room" default="department/room"]. 
-Patient moved to [var name="room"] on stretcher and [textarea name="transferfromstrecher" value="transferred to hospital bed by sheet lift"]. 
-All of patient's belongings were [var name="belongings" ]. 
-Patient care and report given to [text name="tansferofcareR" default="RN"]. 
-Transport signature received from [var name="Signature"]
[conditional field="Signature" condition="(Signature).isNot('Patient')"]
Reason why patient did not sign: [checkbox name="Whynopt" value="patient is a Minor| Patient is unconscious| Patient is mentally incapacitated| Patient under the influence of drugs or alcohol|Patient is restrained and unable to sign| Patient is in great pain| patient is to weak"]
[text name="AR" default=""][/conditional]



Name: [var name="rw"]
Cert: [var name=="rwcert" ]
[date name="date3" default="timestamp"]






[/conditional]