WFEMS

[select name="unit" value="EC1|EC2|EC3|EC5|EC6|EC7|MEDIC 1"] was dispatched to the listed location for a [text name="disp" default="Call Type"]. [var name="unit"] responded [select name="respmode" value="emergent|non-emergent"] [select name="lights" value="With lights and sirens|Without lights and sirens"] and [select name="scene" value="arrived on-scene without incident.|was cancelled en route.|was canceled on scene."] 

Patient complained of [text name="complaint" default="complaint"]

[textarea name="Hx_for_complaint" default="Hx surrounding complaint"] 
Patient's medical history, medications, and allergies documented in appropriate section. 


Appearance: 
Patient was found [text name="ptfound" default="sitting upright..."]and    [checkbox name="pe_general_check" value="well developed, well nourished, and well appearing|in no obvious distress|malnourished|in obvious distress|obese|appears ill|appears frail|obvious signs of death"][text name="pe_general" size = 55 default=" "]
-Airway: [checkbox name="airway" value="maintained by patient|no concerns of compromise|airway patent|no airway obstructions|compromised|airway positioned to open|airway not patent|obstructions to airway|requires airway adjunct|requires advanced airway|requires artificial ventilation"][text name="airway" size = 55 default=" "]
-Breathing: [checkbox name="breathing" value="breathing regular|adequate respirations|appropriate tidal volume|not spontaneously breathing|irregular respirations|inadequate respirations|inadequate tidal volume|breathing spontaneously|rapid|slow|deep|shallow|apneic"][text name="breathing" size = 55 default=" "]
-Circulation: [checkbox name="circulation" value="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|pulses weak|pulses bounding"][text name="ros_constitutional" size = 55 default=" "]
-Level of consciousness: [checkbox name="loc" value="Alert    and    Orientented    x4|alert|oriented|person|place|time |event|disoriented|arousable by verbal stimuli|arousable by painful stimuli|baseline for pt|unresponsive|unconscious|pharmacologically sedated|unresponsive, unconscious, pulseless, and apneic"][text name="consciousness" size = 55 default=" "]

-HEENT: [checkbox name="pe_heent_check" value="eyes PERRL|normal mucousa|no bleeding|no trauma to face or mouth|eyes not PERRL|pupils dilated|pupils constricted|positive halo test|negative halo test|dry mucous membranes|extra salivation|trauma to face|trauma to mouth|bleeding|neck swelling/lumps|glasses|contact lens|dentures|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_heent" default=" "]
-Cardiovascular: [checkbox name="pe_cardio_check" value="regular rate and rhythm without st elevation|regular rate and rhythm|peripheral pulses intact, without cyanosis|irregular rate|Tachycardic|Bradycardic|irregular rhythm|st elevation present|jvd present|edema present|no peripheral pulses|cyanosis present|bleeding|did not assess|unable to assess|unable to assess due accurately to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_cardio" default=" "]
-Respiratory: [checkbox name="pe_resp_check" value="clear to auscultation bilaterally upper/middle/lower lobes|no respiratory distress|bilateral equal rise and fall|barrel chest|tachypnea|bradypnea|no flail segment|unequal chest rise and fall|flail segment|increased work of breathing|wheezing|rales|rhonchi|stridor|pleural rub|retractions|upper respiratory congestion|accessory muscle use|upper airway obstruction|lower airway obstruction|artificial ventilations|did not assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_resp" default=" "]
-ABDOMEN: [checkbox name="pe_gi_check" value="atraumatic, bowel sounds present in all 4 quadrants, abdomen soft/non-tender to palpation|non-distended or rigid, no guarding, no masses|no rebound tenderness|rebound tenderness|trauma present|tender abdomen|rigid abdomen|distended abdomen|guarding present|masses present|left lower quadrant|left upper quadrant|right lower quadrant|right upper quadrant|did not assess|unable to assess due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess accurately to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_gi" default=" "]
-Musculoskeletal: [checkbox name="pe_msk_check" value="normal range of motion|without pain on palpation|no crepitus|no obvious deformity|strength normal in all extremities|fine motorskills intact|abnormal range of motion|pain on palpation|strength not present|crepitus|obvious deformity|in all extremities|left upper extremity|right upper extremity|left lower extremity|right lower extremity|did not assess|unable to assess|unable to assess due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess accurately to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_msk" default=" "]
-Skin: [checkbox name="pe_skin_check" value="no rashes, skin tears, swelling, lesions, or discoloration|pink, warm, and dry, w/ good turgor|pale|cool|cyanotic|flushed|clammy|hot|warm|diaphoretic|lividity|mottling|jaundiced|skin tear|swelling|poor skin turgor|excessively dry skin"][text name="pe_skin" default=" "]
-Neuro: [checkbox name="pe_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|disphagia|aphasia|deceberate posturing|decorticate posturing|seizure activity|strength asymmetrical|gait abnormal|sensation absent|no reflexes|smile asymmetrical|hemiplegia|hemiparesis|slurred speech|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_neuro" default=" "]
-Psych: [checkbox name="pe_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|hostile    to    providers|did not assess|unable to assess|unable to assess accurately due to altered mental state|unable to assess accurately due to level of conciousness|unable to assess to due to unresponsive, unconscious, pulseless, and apneic state"][text name="pe_psych" default=" "]

[textarea name="freestyletreat" default="Treatment"]

Pre-Hospital activations: [checkbox name="pe_act_check" value="Stroke Alert|Trauma Alert|STEMI Alert|Sepsis Alert|No alerts activated"][text name="pe_act" default=" "]

Non-transport Dispositions
[checkbox name="Non-transport Dispositions" value="lift assist only|pt refused ems evaluation & transport|patient refused evaluation|pt refused transport|patient treated and released|Refusal Against Medical Advice (AMA)|per protocol|no transport required|no treatment required|no patient contact|protocol requirements met, termination of cpr|obvious signs of death, considered futile|er physician order for termination|transferred care to another ems unit - ground|transferred care to another ems unit - air"] 

Transport
Pt was moved to stretcher by [checklist name="transportmode" value="walking|backboard|carried|stairchair"] and positioned [select name="pt-transpo-position" value="supine.|low fowler's.|semi-fowler's.|full fowler's/sitting.|prone.|RLR.|LLR."]

Pt was[checkbox name="pe_trans_check" value="secured to stretcher with belts and rails and loaded into ambulance for transport w/o incident.|seated    in    captain's    chair    and    secured.|placed    on    bench    seat    and    secured."]

Pt was transported [select name="transport priority" value="emergent/lights and sirens|non-emergent/no lights and sirens|emergent downgraded to non-emergent/no lights and siren|non-emergent upgraded to emergent/lights and siren"] to [select name="hospital" value="Clark Regional Medical Center.|Univeristy of Kentucky- Chandler.|University of Kentucky- Good Samaritan|St. Joesph Main.|St. Joseph East.|St. Joesph- Mt. Sterling.|Baptist Health- Hamburg.|Baptist Health- Lexington.|Bourbon Community Hospital.|Cardinal Hill Hospital.|Pattie A. Clay Regional Medical Center.|VA Medical Center."]  

While enroute, pt report was called by [checklist name="report-method" value="phone|radio|dispatcher"] to [var name="hospital"]

Upon arrival, pt was moved inside and [var name="unit"] was directed to [text name="hospassign" default="Room or Triage"]. Patient  was transferred to [select name="endposition" value="hospital bed|chair|wheelchair"] without incident.
Report: Patient care report given to RN [text name="RNname" default="sample text"] at bedside;prior to signing for patient care, they were given the opportunity to ask any questions, state any comments or address any concerns
Signatures: [checkbox name="signature" value="obtained from patient|obtained from guardian/poa|obtained from responsible party|unable to sign|law enforcement signed as|nurse signed as|ems crew signed as| representative|witness|no representative available"][text name="pe_signature" default=" "]

[var name="unit" default="unit"] cleared and returned to service.

[text name="rw" default="Provider"]
[text name="rwcert" default="Cert"]