Assessment & Plan Elements
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TO BE SAVED

APPARATUS: [checkbox name="APPARATUS" value="MEN 1.|MEN 2.|MEN 3.|MEN 4.|MEN 5.|MEN 6| MEN 7| MEN 8| MEN 9| MEN 10.|MEN 11| MEN 12.|MEN 13.| MEN 14| MEN 15 |AM-17| AM-60| MEDIC 25 "][text name="APPARATUS" default=" "]

RESPONSE: [checkbox name="RESPONSE" value="EMERGENT.|NONEMERGENT.|LIGHTS/SIRENS.|LIGHTS NO SIRENS.|NO LIGHTS NO SIRENS.|UPGRADED TO EMERGENT.|DOWNGRADED TO NONEMERGENT|INTERFACLTY TRANSFER."][text name="RESPONSE" default=" "]

DISPATCHED TO:[textarea name="dispatch" default=" "]


ATF, [text name="variable_1" default=" "] year old
[select name="variable_1" value=" MALE|FEMALE|"]:[textarea name="arrived" default=" "]

CHIEF COMPLAINT: [text name="CC" size = 55 default=" "]

SECONDARY COMPLAINT(s):[text name="CC" size = 55 default=" "]
**************************************************
COVID-19 QUESTIONS:

Close contact with person with confirmed or suspected COVID-19: [select name="variable_2" value="NO|YES"]

Travel to high risk COVID-19 areas per current local guidance: [select name="variable_3" value="NO|YES"]

SYMPTOMS:

[checklist name="variable_1" value="+Shortness of breath|-Shortness of breath|+Cough|-Cough|+Fever|-Fever|+Sore throat|-Sore throat|+Loss of smell|-Loss of smell|+Nausea|-Nausea|+Vomiting|-Vomiting|+Flu like Sx|-Flu like Sx"]
[checklist name="variable_1" value="+instability or deformity|-instability or deformity|+ abrasions or bruising|-abrasions or bruising|+crepitus|-crepitus|+bone movement|-bone movement|+pain upon palpation|-pain upon palpation”]

Onset: [text name="Onset"]

Quarantine: [checkbox name="Quarantineintiated" value="Yes |No"] Isolation: [checkbox name="Isolationintiated" value="Yes |No"]


Symptoms are [select name="variable_4" value="IMPROVING|WORSENING|STAYING THE SAME"] since onset.
***********************************************


HX OF PRESENT ILLNESS/INJURY:[textarea name="HX_OF_PRESENT_ILLNESS" default=" "]
PAST MEDICAL Hx: [textarea name="pmhx" default=" "]

ALLERGIES: [checkbox name="allergies_check" value="NKDA.|PENICILLIN.|SULFA.|LATEX."][text name="allergies" default=" "]

[textarea name="variable_1" default="what were you doing when the pain started?"]
[textarea name="variable_1" default="how long the pain lasted? Was the onset was sudden or gradual"]
[textarea name="variable_1" default="factors that ease or aggravate the pain?"]
[textarea name="variable_1" default="the pain's exact location. Ask him to point to the pain and record his response. For example, he may move his hand vaguely around his abdomen or point with one finger to his left chest"]
[textarea name="variable_1" default="whether the pain radiates, and if so, where"]
[textarea name="variable_1" default="pain severity. Ask him to rate his pain on a pain intensity scale where 0 is no pain and 10 is the worst pain imaginable"]

The patient is a [text default="AGE + GENDER"] who presents to the ED complaining of [text default="CHIEF COMPLAINT"] that began [text default="ONSET"] while [text default="CONTEXT"]. Symptoms have been [text default="TIMING"] since onset and he/she rates them as [text default="SEVERITY"] in severity. Patient reports the symptoms are located [text default="LOCATION"] and describes the quality as [text default="QUALITY"]. Per patient, he/she has had associated [text default="POSITIVE SYMPTOMS"] but denies any [text default="NEGATIVE SYMPTOMS"]. Symptoms are improved with [text default="MODIFYING FACTOR"] and exacerbated by [text default="MODIFYING FACTOR"]. Patient [text default="REPORTS/DENIES"] history of similar symptoms. Pertinent medical history includes [text default="PERTINENT PAST MEDICAL HISTORY"]. Patient adds [text default="OTHER DETAILS"].




Initial ABC's:
-Airway: [checkbox name="airway" value="airway open.|airway patent.|no airway obstructions.|Normal.|airway positioned to open.|airway not patent.|obstructions to airway.|requires airway adjunct.|requires advanced airway.|requires artificial ventilation."][text name="airway" default=" "]

-Breathing: [checkbox name="breathing" value="breathing spontaneously.|breathing regular.|adequate respirations.|appropriate tidal volume.|no apparent life threats to breathing.|Normal.|not breathing spontaneously.|irregular respirations.|inadequate respirations.|inadequate tidal volume.|apparent life threats to breathing."][text name="breathing" default=" "]

-Circulation: [checkbox name="circulation" value="no obvious bleeding.|pulses intact.|skin color appropriate.|cap refill <2 seconds.|no life treats to circulation status.|normal.|hemorrhage present.|hemorrhage controlled.|tq applied.|pulses not intact.|skin color not appropriate.|cap refill >2 seconds.|life threatening concerns with circulation."][text name="ros_constitutional" default=" "]


PHYSICAL EXAM
-Blood Pressure: [text name="pe_bp" default=" "]
-Pulse: [text name="pe_pulse" default=" "]
-SPO2: [text name="pe_spo2" default=" "]
-BGL: [text name="pe_bgl" default=" "]
-General: [checkbox name="pe_general_check" value="Well developed/well nourished.|Well appearing.|in no acute distress.|malnourished.|in acute distress.|obese."][text name="pe_general" default=" "]
-HEENT: [checkbox name="pe_heent_check" value="normocephalic.|atraumatic.|PERRLA.|white sclera.|conjunctiva pink/red|no fluid noted in or around ears.|no bleeding.|bleeding.|positive HALO test.|negative HALO test.|dry mucous membranes.|extra salivation. |normal mucous.|normal pharynx.|no trauma to mouth.|Normal.|trauma to face.|trauma to mouth.|patient denies vision changes.| patient denies ear pain.|no nasal congestion.| patient denies sore throat.|no cough."][text name="pe_heent" default=" "]
-Cardiovascular: [checkbox name="pe_cardio_check" value="Regular rate and rhythm.|no ST elevation.|no jugular vein distention.|no edema.|peripheral pulses intact.|no cyanosis.|capillary refill < 2 seconds.|Normal.|irregular rate.|irregular rhythm.|ST elevation present.|JVD present.|edema present.|no peripheral pulses.|cyanosis present.|capillary refill greater than 2 seconds.|bleeding.|trauma.|atraumatic."][text name="pe_cardio" default=" "]
-Respiratory: [checkbox name="pe_resp_check" value="Clear to Auscultation bilaterally.|no rales, rhonchi, wheezes.|no retractions.|no accessory muscles being used.|no stridor.|Normal.|wheezing.|upper respiratory congestion.|Diminished breath sounds."][text name="pe_resp" default=" "]
-GI: [checkbox name="pe_gi_check" value="atraumatic.|BS present in all 4 quadrants.|abdomen soft/non-tender to palpation.|non-distended.|No rigidity.|no guarding.|no masses.|Normal.|Trauma present.|Tender abdomen.|Rigid abdomen.|distended abdomen.|Guarding present.|masses present."][text name="pe_gi" default=" "]
-MSK: [checkbox name="pe_msk_check" value="normal Range of movement.|no pain on palpation.|strength 5/5 in all extremities.|Normal.|abnormal range of motion.|pain on palpation.|strength not present in all extremities."][text name="pe_msk" default=" "]
-pelvic examine:
[checklist name="variable_1" value="+instability or deformity|-instability or deformity|+abrasions or bruising|-abrasions or bruising|+crepitus|-crepitus|+bone movement|-bone movement|+pain upon palpation|-pain upon palpation"]
-Skin: [checkbox name="pe_skin_check" value="no rash.|no lesion.|no discoloration.|pink.|warm.|dry.|pale.|cool.|cyanotic.|flushed.|clammy.|hot.|Normal."][text name="pe_skin" default=" "]
-Neuro: [checkbox name="pe_neuro_check" value="Grossly oriented X 4.|gait normal.|sensation intact.|normal reflexes.|smile normal.|speech not slurred.|Normal.|Neuro not grossly intact.|gait abnormal.|sensation absent.|no reflexes.|smile not symmetrical.|slurred speech."][text name="pe_neuro" default=" "]
-Psych: [checkbox name="pe_psych_check" value="Pleasant, calm and cooperative.|Judgement and insight intact.|makes a plan.|understands treatment.|thought process normal.|normal affect.|At baseline.|unpleasant.|not calm.| not cooperative.|does not make plan.|does not understand treatment."][text name="pe_psych" default=" "]
-Hematologic: [checkbox name="pe_heme_check" value="no tenderness or masses palpated.|no bruises.|no bleeding.|Normal.|tenderness/masses.|bruising.|bleeding."][text name="pe_heme" default=" "]

Chest pain
Onset [text] prior to evaluation
Onset while: [text]

Associated Pain
Location: [text]
Radiation: [text]
Severity now: [text]
Duration: [text]
Characterized as: [text].

associated Pain (0=none, 10=severe)
Location: [text]
Radiation: [text]
Severity now (0-10): [text]
Severity at worst (0-10): [text]
Duration: [text]
Characterized as: [text].

Associated Symptoms:
[select value="no|YES"] <-- nausea/vomiting
[select value="no|YES"] <-- diaphoresis
[select value="no|YES"] <-- shortness of breath

Pertinent PMH
[select value="no|YES"] <-- Coronary Disease
[select value="no|YES"] <-- Cerebrovascular disease
[select value="no|YES"] <-- Diabetes Mellitus
[select value="no|YES"] <-- Peptic Ulcer or GERD
[select value="no|YES"] <-- Chest injury or overuse

Pertinent Medications:
[select value="no|YES"] <-- Aspirin was taken today
[select value="no|YES"] <-- Nitroglycerin

Pitfalls:
[select value="no|YES"] <-- unilateral leg swelling


Cardiovascular risks are reviewed as follows:
Tobacco use: [text]
Hyperlipidemia: [text]
Hypertension: [text]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: contributed by Dr. Scott Moses, creator/author of the [link url="http://www.fpnotebook.com" memo="FP Notebook Site"] Family Practice Notebook[/conditional]

The pain is relieved with [text]
[select value="no|YES"] <-- OTC NSAID's
[select value="no|YES"] <-- Rest
[select value="no|YES"] <-- ASA
[select value="no|YES"] <-- NTG
[select value="no|YES"] <-- Oxygen

The pain is worse with [text]
[select value="no|YES"] <-- supine or leaning forward ( concern for pericarditis)
[select value="no|YES"] <-- movement
[select value="no|YES"] <-- exertional pain
[select value="no|YES"] <-- pleuritic pain

Pertinent PMH
[select value="no|YES"] <-- Coronary Disease
[select value="no|YES"] <-- Cerebrovascular disease
[select value="no|YES"] <-- Diabetes Mellitus
[select value="no|YES"] <-- Peptic Ulcer or GERD
[select value="no|YES"] <-- Chest injury or overuse
[select value="no|YES"] <-- ETOH use
[select value="no|YES"] <-- drug use

Cardiovascular risks are reviewed as follows:


[select name="Q1" value="no=0|YES=1"] <-- Male 55 years or over/Female 65 or over
[select name="Q2" value="no=0|YES=1"] <-- Known CAD or cerebrovascular disease
[select name="Q3" value="no=0|YES=1"] <-- Pain not reproducible by palpation
[select name="Q4" value="no=0|YES=1"] <-- Pain worse during exercise
[select name="Q5" value="no=0|YES=1"] <-- Patient assumes pain is cardiogenic

Plan:

[checkbox name="variable_1" value="324 ASA PO|SL NTG 0.04 mg|Oxygen|Saline lock in place| Morphine sulfate "]

TREATMENT: [textarea name="Treatment" default=" "]

TRANSPORT: [checkbox name="pe_trans_check" value="Secured to stretcher.|3 straps.|loaded for transport.|Emergency.|Non Emergency.|Emergency Downgraded to Non Emergency.|Non Emergency Upgraded to Emergency.|refusal.|AMA.|treat and release.|no transport.|lift assist only.|transported to ER."][text name="pe_trans" default=" "]

REPORT: [checkbox name="pe_rep_check" value="Verbal report to nurse.|belongings left with nurse.|improvement in patient condition.|decline in patient condition.|no change in patient condition."][text name="pe_rep" default=" "]

IV Attempt times [select name="variable_1" value="1|2|3"]
Good Flash, Good Flush. Site covered with [select name="variable_1" value="with tape in two spots|foam strips from Tegaderm package in two spots|"]

Unable to start IV. Upon cannulation of the vein, [select name="variable_1" value="the site above became swollen|the patient complained of pain|"] [select name="variable_1" value="no flash|unable to flush|"] When IV removed no blood from the puncture site. Site covered with (1) folded 2X2 and secured with tape.

Radio report to [select name="variable_1" value="Oswego ER|SUNY Upstate ER|St. Joe’s ER|Crouse ER| Syracuse VA ER"]No questions at this time. Clear for transport.
[text name="variable_1" default="sample text"]

Report to [select name="variable_1" value="Oswego ER|SUNY Upstate ER|St. Joe’s ER|Crouse ER| Syracuse VA ER"] triage staff.
Patient to room [text name="variable_1" default=" "]

Ambulance stretcher [select name="variable_1" value="raised to height of hospital bed|to lowest position|"] and with the assistants of [select name="variable_1" value="1|2|3|4"] patient moved over to [select name="variable_1" value="hospital bed|ambulance stretcher|"].

Signatures: [checkbox name="pe_rep_check" value="obtained from patient|obtained from guardian/POA|refusal of treatment and or transport|not obtained from patient|unable to sign|no representative available.|Nurse signed as witness.|refusal signature witnessed by"][select name="variable_1" value="spouse/significant other|sibling|adult child|other"]
[text name="pe_rep" default=" "]

Provider writing report: [text name="RW" default=" "]
TO BE SAVED

APPARATUS:

RESPONSE:

DISPATCHED TO:


ATF, year old
:

CHIEF COMPLAINT:

SECONDARY COMPLAINT(s):
**************************************************
COVID-19 QUESTIONS:

Close contact with person with confirmed or suspected COVID-19:

Travel to high risk COVID-19 areas per current local guidance:

SYMPTOMS:




Onset:

Quarantine: Isolation:


Symptoms are since onset.
***********************************************


HX OF PRESENT ILLNESS/INJURY:
PAST MEDICAL Hx:

ALLERGIES:








The patient is a who presents to the ED complaining of that began while . Symptoms have been since onset and he/she rates them as in severity. Patient reports the symptoms are located and describes the quality as . Per patient, he/she has had associated but denies any . Symptoms are improved with and exacerbated by . Patient history of similar symptoms. Pertinent medical history includes . Patient adds .




Initial ABC's:
-Airway:

-Breathing:

-Circulation:


PHYSICAL EXAM
-Blood Pressure:
-Pulse:
-SPO2:
-BGL:
-General:
-HEENT:
-Cardiovascular:
-Respiratory:
-GI:
-MSK:
-pelvic examine:

-Skin:
-Neuro:
-Psych:
-Hematologic:

Chest pain
Onset prior to evaluation
Onset while:

Associated Pain
Location:
Radiation:
Severity now:
Duration:
Characterized as: .

associated Pain (0=none, 10=severe)
Location:
Radiation:
Severity now (0-10):
Severity at worst (0-10):
Duration:
Characterized as: .

Associated Symptoms:
<-- nausea/vomiting
<-- diaphoresis
<-- shortness of breath

Pertinent PMH
<-- Coronary Disease
<-- Cerebrovascular disease
<-- Diabetes Mellitus
<-- Peptic Ulcer or GERD
<-- Chest injury or overuse

Pertinent Medications:
<-- Aspirin was taken today
<-- Nitroglycerin

Pitfalls:
<-- unilateral leg swelling


Cardiovascular risks are reviewed as follows:
Tobacco use:
Hyperlipidemia:
Hypertension:
display/hide references

The pain is relieved with
<-- OTC NSAID's
<-- Rest
<-- ASA
<-- NTG
<-- Oxygen

The pain is worse with
<-- supine or leaning forward ( concern for pericarditis)
<-- movement
<-- exertional pain
<-- pleuritic pain

Pertinent PMH
<-- Coronary Disease
<-- Cerebrovascular disease
<-- Diabetes Mellitus
<-- Peptic Ulcer or GERD
<-- Chest injury or overuse
<-- ETOH use
<-- drug use

Cardiovascular risks are reviewed as follows:


<-- Male 55 years or over/Female 65 or over
<-- Known CAD or cerebrovascular disease
<-- Pain not reproducible by palpation
<-- Pain worse during exercise
<-- Patient assumes pain is cardiogenic

Plan:



TREATMENT:

TRANSPORT:

REPORT:

IV Attempt times
Good Flash, Good Flush. Site covered with

Unable to start IV. Upon cannulation of the vein, When IV removed no blood from the puncture site. Site covered with (1) folded 2X2 and secured with tape.

Radio report to No questions at this time. Clear for transport.


Report to triage staff.
Patient to room

Ambulance stretcher and with the assistants of patient moved over to .

Signatures:


Provider writing report:

Result - Copy and paste this output:
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