BHFR DETAILED TRANSFER FORM

DISPATCH: [textarea name="dispatch" default=" "]

ARRIVED: [textarea name="arrived" 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|OBGYB|STROKE|TRAUMA|BURN UNIT|CRITICAL CARE"][text name="TRANSFER" default=" "]

PATIENT CRITICALLY ILL PER PCS: [checkbox name="CCT" value="YES|NO"]

PATIENT BEDBOUND PER PCS BY 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 ERECT UNASSISTED IN CHAIR OR WHEELCHAIR FOR A DURATION/ANY PART OF TRIP"]

PATIENT REQUIRED: [checkbox name="CARE" value="CARDIAC MONITORING|IV FLUID MANAGEMENT|IV PUMP MANAGEMENT|OXYGEN ENROUTE|AIRWAY MANAGEMENT|NEBULIZED TREATMENT DURING TRANSPORT|SPECIAL ORTHOPEDIC HANDLING|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 ACLS DRUGS PRESENT DURING TRANSPORT"][text name="ros_heme" default=" "]

PHYSICIANS DIAGNOSIS: [text name="CC" default=" "]

Hx:
Onset Of Current Complaint: [text name="O" size = 55 default=" "]
Provoking/Relieving Factors: [text name="P" size = 55 default=" "]
Quality/Described As: [text name="q" size = 55 default=" "]
Radiation: [text name="r" size = 55 default=" "]
Severity: [text name="s" size = 55 default=" "]
Hx of Present Illness including hospital treatment and diagnostics: [textarea name="hpi" default=" "]

PMHx: [textarea name="pmhx" default=" "]

ALLERGIES: [checkbox name="allergies_check" value="NKDA"][textarea name="allergies" default=" "]

INITIAL ABC's:
-AIRWAY: [checkbox name="airway" value="NORMAL AIRWAY OPEN, PATENT, AND WITHOUT OBSTRUCTIONS|PATIENT ON CPAP|PATIENT INTUBATED AND ON VENTILATOR|SECRETIONS IN ENDOTRACHEAL TUBE REQUIRING SUCTION|ON NASAL CANNULA WITH OXYGEN BETWEEN 2-6 LITERS PER MINUTE|ON NON REBREATHER WITH OXYGEN BETWEEN 12-15 LITERS PER MINUTE|RECEIVING NEBULIZED BREATHING TREATMENT"][text name="airway" default=" "]

-BREATHING: [checkbox name="breathing" value="NORMAL BREATHING WITH ADEQUATE RATE AND TIDAL VOLUME|BREATHING RATE AND VOLUME CONTROLLED BY VENTILATOR"][text name="breathing" default=" "]

-CIRCULATION: [checkbox name="circulation" value="NORMAL, PULSES INTACT, SKIN COLOR AND TEMPERATURE APPROPRIATE|WITHOUT PRESENCE OF OBVIOUS LIFE THREATS TO CIRCULATION|HEMORRHAGE PRESENT BUT CONTROLLED BY PRIOR INTERVENTIONS|PULSES NOT INTACT AS NOTED|SKIN COLOR AND TEMPERATURE 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|CHEMICALLY SEDATED"][text name="consciousness" size = 55 default=" "]

TREATMENT: [checkbox name="treatment" value="PRIMARY AND SECONDARY ALS ASSESSMENT|PRIMARY AND SECONDARY BLS ASSESSMENT|CONTINUOUS CARDIAC MONITORING"] [textarea name="rxt" default=" "]

TRANSPORT: [checkbox name="pe_trans_check" value="SECURED PATIENT TO STRETCHER WITH 3 STRAPS AND RAILS UPRIGHT|LOADED INTO AMBULANCE FOR TRANSPORT|EMERGENCY|NON EMERGENCY|TRANSPORTED TO FLOWERS HOSPITAL|TRANSPORTED TO SOUTHEAST ALABAMA MEDICAL CENTER|TRANSPORTED TO DALE MEDICAL CENTER|TRANSPORTED TO MEDICAL CENTER BARBOUR"][text name="pe_trans" default=" "]

REPORT: [checkbox name="pe_rep_check" value="VERBAL REPORT TO NURSE|PATIENT BELONGINGS LEFT WITH NURSE|IMPROVEMENT IN PATIENT CONDITION|DECLINE IN PATIENT CONDITION|NO CHANGE IN PATIENT CONDITION"][text name="pe_rep" default=" "]

REPORT WRITER: [checkbox name="pe_RW_check" value="MNL PARAMEDIC 0500209|JLKP PARAMEDIC 1900992|KJT PARAMEDIC 1100854|WJW ADVANCED 1900975|HH AEMT 1500443|JSG AEMT 1700407|GEL EMT 1700263|SMDL EMT 1000371|VRP EMT 2200028|BRF EMT 2200471|ABE EMT 2300191|TJC EMT 2300322|CHS EMT 2301091|SRC EMT 2301101|FSG EMT 2301127"][text name="RW" default=" "]