Valor EPCR

[comment memo="INITIAL PICKUP AND DESTINATION LOCATIONS ARE REQUIRED, AFTER INITIAL, REMAINDER WILL BE AUTO GENERATED"]
D- Valor Squad [select name="ID" value="1946|1945|1947|1948|1949"] was requested  [select name="Responsetype" value="Non-Emergent |Emergent "]for transport of a PT from [text name="pickup" default=""][comment memo="Pickup Facility"] to be transported to [text name="destination" default=""][comment memo="destination facility"] for a [select name="typeofcall" value="scheduled|non-scheduled"] transport.

C- The Patient is being transported from [text name="pickup" default=""][comment memo="Pickup    Facility"] to [text name="destination" default=""][comment memo="destination facility"] due to the sending facility not having the capability to provide necessary treatments and exams. 
The PT requires [comment memo="List Specific reason the PT is going for appointment"][textarea name="specifics" default=""]

H- Staff report the PT has been diagnosed with [comment memo="diagnosis by which the PT is being transported for"] [textarea name="diagnosis" default=""]
The PT has a medical history of [checkbox name="variable_1" value="COPD|CHF|HTN|chronic renal failure/ckd|diabetes|cardiac arrhythmias|cardiac condition|cardiac stent|dementia|parkinson’s disease|A-Fib|A-flutter|pacemaker|blood disorder|decubitus ulcers|obesity|anxiety|depression|arthritis|asthma|bi-polar|cancer|cardiac condition|cellulitis|hepitisis|gallbladder disease|gout|kidney stones|CVA/stroke|amputee|anemia|anoxic brain injury|autistic disorder|chronic pain|drug abuse|alcohol abuse|cirrhosis of liver|colostomy|contractures|crohn’s disease|DVT|diverticulitis|edema|seizures/epilepsy|gastric bypass surgery|history of falls|thyroid disease|infectious disease|neuropathy|osteoarthritis|pneumonia|substance abuse|tremors|vertigo"][text name="otherhistorynotlisted" default=""] [comment memo="List any other medical history not listed"] 
The PT has allergies to [checkbox name="allergies" value="PCN|Sulfa|amoxicillin|aspirin|codeine|morphine|Statins|cepro|cillins|NKDA"] [text name="allergiesnotlisted” default=""]. [comment memo="List any other allergies not listed"] 
The PT takes various meds which are listed in the EPCR report. 

A- Upon arrival to the PT, they are found [comment memo="Where and how was the PT found"]    [textarea name="ptlocation" default=""] 
Assessment: 
General overall appearance: [textarea name="appearance" default="the patient appears to be in no pain or distress at this time. "]
Airway: [checkbox name="airway" value="open, maintained by patient, with no concern for compromise|open|maintained by patient|no concerns for compromise|not open|compromised|requires manual opening|requires airway adjunct|requires advanced airway"][text name="airway" size = 55 default=" "][comment memo="Any other conditions not listed"]
Breathing: [checkbox name="breathing" value="breathing spontaneously, non-labored, with a regular rate and adequate tidal volume.|tachypneic|deep|bradypneic|shallow|agonal|apneic "][text name="breathing" size = 55 default=" "][comment memo="Any other conditions not listed"]
Circulation: [checkbox name="circulation" value="normal and without concerns. |regular and normal pulse rate|tachycardic|bradycardic|weak pulse|massive hemorrhage|diminished perfusion|pulseless "][text name="circulation" size = 55 default=" "][comment memo="Any other conditions not listed"]
Level of consciousness: [checkbox name="loc" value="alert and oriented to person, place, time, and event|alert|oriented|disoriented|person|place|time|event|arousable by verbal stimuli|arousable by painful stimuli|unresponsive"][text name="consciousness" size = 55 default=" "][comment memo="Any other conditions not listed"]
Skin: [checkbox name="skin" value="pink, warm, and dry|pale, cool, and clammy|pink|warm|dry |pale|cool|clammy|diaphoretic|hot|flushed|cyanotic|lividity|jaundiced"][text name="skin" size = 55 default=" "][comment memo="Any other conditions not listed"]
HEENT: [checkbox name="head" value="normal and unremarkable|no reported pain|pupils equally round and reactive|pupils unequal"]
Neck: [checkbox name="neck" value="normal and unremarkable|jvd|no jvd|tracheal deviation|no tracheal deviation|no reported pain"][text name="neck" size = 55 default=" "][comment memo="Any    other conditions not listed"]
Chest: [checkbox name="chest" value="normal and unremarkable|breath sounds clear equal bilaterally|no reported pain"][text name="chest" size = 55 default=" "]
Back: [checkbox name="back" value="normal and unremarkable|no reported pain"][text name="back" size = 55 default=" "][comment memo="Any other conditions not listed"]
Abdomen: [checkbox name="abdomen " value="soft, non-tender, unremarkable|no pain"][text name="abdomen" size = 55 default=" "][comment memo="Any other conditions not listed"]
Pelvis: [checkbox name="pelvis" value="normal and unremarkable|no reported pain "][text name="pelvis" size = 55 default=" ][comment memo="Any other conditions not listed"]
Extremities: [checkbox name="extremities" value="normal and unremarkable|equal strength x4 |unequal strength|cap refill less than 2 seconds|no reported pain "][text name="extremities" size = 55 default=" "][comment memo="Any other conditions not listed"]
additional assessment findings: [comment memo="Any other conditions not listed"] [textarea name="additassess" default=" "]
Pain level reported as [select name="variable_6" value="0|1|2|3|4|5|6|7|8|9|10"]
After initial assessment, the PT was moved from bed to ems cot and placed in position of comfort then secured with provided straps and rails up and locked.  Once in ems unit, baseline vitals were obtained and recorded as: 
HR:[text name="0" default=""]
RR:[text name="0" default=""]
BP:[text name="0" default=""]
BGL:[text name="0" default=""]
SPO2:[text name="0" default=""]

R- Treatment during transport included the following: [comment memo="ALS or BLS assessment, O2, IV, etc."][textarea name="treatments" default="treatments"].

Destination vitals were obtained and recorded as:
HR:[text name="0" default=""]
RR:[text name="0" default=""]
BP:[text name="0" default=""]
BGL:[text name="0" default=""]
SPO2:[text name="0" default=""]

T - The PT was transported by Ambulance via EMS cot and secured with provided straps to [text name="destination" default=""]in [select name="position" value="fowlers|semi-fowlers|supine|prone|sitting|on left    side|on Right Side"] position. The PT condition [checkbox name="condition" value="improved|was unchanged|got worse"] during transport and upon arrival to [text name="destination" default=""][comment memo="destination facility"] The PT was moved to [text name="room" default=""].[comment memo="Location were PT was moved too"] 
Care and report given to [text name="nursename" default="first/last name"]
[checkbox memo="" name="VAC444444" value="Medical Necessity Statement:"] [comment memo="Required on all convalescent/IFT transports. Select ALL that apply."][conditional field="VAC444444" condition="(VAC444444).is('Medical Necessity Statement:')"] The patient requires ambulance transportation due to [checkbox name="" value="Inability to get up from bed without assistance, inability to ambulate, and inability to sit in a chair or wheelchair|Could be moved only by stretcher|Is confused combative, lethargic, or comatose|Is a flight risk|Moderate  /Severe pain on    movement|Danger  to self/others|Required physical or chemical restraint to prevent injury to the beneficiary or others|Had to remain immobile because of a fracture that had not been set or the possibility of a fracture|Severe vertigo causing inability to remain upright|Needed advanced airway management (ventilator dependent, apnea monitor, possible intubation needed, deep suctioning)|Required cardiac/hemodynamic monitoring|Required non-self-administered IV meds en route|Required suctioning en route per transfer instructions|Required airway control/positioning en route per transfer instructions|Required third party assistance/attendant to apply, administer or regulate oxygen en route. Does not apply to patient capable of self-administration of portable or home 02. Patient is so frail as to require oxygen assistance.|Has a condition such that patient risks injury during vehicle movement despite restraints|Has morbid obesity which requires additional personnel or equipment to handle|Has a communicable disease or hazardous material exposure and must be isolated from the public or whose medical condition must be protected from public exposure|Has an orthopedic device that requires special handling en route (backboard, halo traction, use of pins and traction)|Has severe pain aggravated by transfers or moving vehicle such that trained expertise of EMT is required. Pain is present, but is not sole reason for transport.|Required positioning special handling to avoid further injury (less than grade 2 decubiti on buttocks).|Required positioning special handling that is inappropriate in a wheelchair or standard car seat due to contractures or recent extremity fracture|DVT requiring elevation of lower extremity|Contractures|Severe muscular weakness and de-conditioned state precludes any significant physical activity|Requires a higher level of care/specialty care unit unavailable at referring facility|Requires a procedure unavailable at referring facility|Non-healded    fractures|other"][textarea name="variable_20" default=""][/conditional]

[checkbox memo="" name="VAC555555" value="Authorization for Information Release:"][comment memo="Required on all transports. If the patient is unable to sign you must select the individual signing on behalf of the patient AND select the last field notating why the patient was unable to sign."][conditional field="VAC555555" condition="(VAC555555).is('Authorization for Information Release:')"] The Authorization for Information Release and Notice of Privacy Practices acknowledgement has been captured electronically by the following: [checkbox name="" value="The patient.|The patient's legal guardian.|Relative or other person who receives social security or other governmental benefits.|Relative or other person who arranges for the patient's treatment or exercise other responsibility for the patient's affairs on behalf of the patient.|Representative of an agency or institution that did not furnish the services for which payment is claimed but furnished other care, services or assistance to the patient.|The patient was unable to sign the Authorization for Information Release and Notice of Privacy Practices necessitating an authorized representative signature due to"][textarea name="variable_20" default=""][/conditional]

[text name="variable_18" default="YOUR NAME"] [text name="variable_19" default="CERT #"]
INITIAL PICKUP AND DESTINATION LOCATIONS ARE REQUIRED, AFTER INITIAL, REMAINDER WILL BE AUTO GENERATED
D- Valor Squad was requested for transport of a PT from Pickup Facility to be transported to destination facility for a transport.

C- The Patient is being transported from Pickup Facility to destination facility due to the sending facility not having the capability to provide necessary treatments and exams.
The PT requires List Specific reason the PT is going for appointment


H- Staff report the PT has been diagnosed with diagnosis by which the PT is being transported for

The PT has a medical history of List any other medical history not listed
The PT has allergies to . List any other allergies not listed
The PT takes various meds which are listed in the EPCR report.

A- Upon arrival to the PT, they are found Where and how was the PT found

Assessment:
General overall appearance:

Airway: Any other conditions not listed
Breathing: Any other conditions not listed
Circulation: Any other conditions not listed
Level of consciousness: Any other conditions not listed
Skin: Any other conditions not listed
HEENT:
Neck: Any other conditions not listed
Chest:
Back: Any other conditions not listed
Abdomen: Any other conditions not listed
Pelvis: Any other conditions not listed
Extremities: Any other conditions not listed
additional assessment findings: Any other conditions not listed

Pain level reported as
After initial assessment, the PT was moved from bed to ems cot and placed in position of comfort then secured with provided straps and rails up and locked. Once in ems unit, baseline vitals were obtained and recorded as:
HR:
RR:
BP:
BGL:
SPO2:

R- Treatment during transport included the following: ALS or BLS assessment, O2, IV, etc.
.

Destination vitals were obtained and recorded as:
HR:
RR:
BP:
BGL:
SPO2:

T - The PT was transported by Ambulance via EMS cot and secured with provided straps to in position. The PT condition during transport and upon arrival to destination facility The PT was moved to .Location were PT was moved too
Care and report given to
Required on all convalescent/IFT transports. Select ALL that apply.

Required on all transports. If the patient is unable to sign you must select the individual signing on behalf of the patient AND select the last field notating why the patient was unable to sign.


Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.37, 93 form elements, 212 boilerplate words, 33 text boxes, 8 text areas, 19 checkboxes, 5 drop downs, 26 comments, 2 conditionals, 223 total clicks
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