MILLIS FIRE

APPARATUS: [checkbox name="APPARATUS" value="Ambulance 2|Ambulance 1|Engine 2|Ladder 1|Car 2|Car 1"][text name="APPARATUS" default=" "]
DISPATCHED TO:[textarea name="dispatch" default=" "]
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UPON ARRIVAL: [textarea name="arrived" default=" "]

AGE/SEX: [text name="AGE/SEX" size = 55 default=" "]

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

SECONDARY COMPLAINT(s): [text name="CC" size = 55 default=" "]


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

ALLERGIES:[checkbox name="allergies_check" value="NKDA"][text name="allergies" default=" "]
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Initial ABC's:
-Airway: [checkbox name="airway" value="airway open.|airway patent.|no airway obstuctions.|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.|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 >2seconds.|no life treats to circulation status.|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=" "]
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REVIEW OF SYMPTOMS:
-Constitutional: [checkbox name="ros_constitutional_check" value="no fever.|no chills.|no weakness.|no fatigue.|fever.|chills.|weakness."][text name="ros_constitutional" default=" "]
-HEENT: [checkbox name="ros_heent_check" value="no vision changes.|No ear pain.|no nasal congestion.|no sore throat.|no cough."][text name="ros_heent" default=" "]
-Cardiovascular: [checkbox name="ros_cardio_check" value="No chest pain|no palpitations.|no swelling of extremities.|chest pain.|palpitations.|swelling of extremities."][text name="ros_cardio" default=" "]
-Respiratory:[checkbox name="ros_resp_check" value="No shortness of breath.|no hemoptysis.|no dyspnea.|shortness of breath.|hemoptysis.|dyspnea."][text name="ros_resp" default=" "]
-GI: [checkbox name="ros_gi_check" value="No change in appetite.|no abdominal pain.|no hematemesis.|change in appetite.|no N/V/D.|Abdominal pain.|hematemesis.|Nausea.|Vomiting.|Diarrhea."][text name="ros_gi" default=" "]
-GU: [checkbox name="ros_gu_check" value="no urinary frequency.|no urinary urgency.|no dysuria.|no hematuria.|no leakage of urine.|urinary frequency.|urinary urgency.|dysuria.|hematuria.|leakage of urine."][text name="ros_gu" default=" "]
-MSK: [checkbox name="ros_msk_check" value="no back pain.|no joint pain.|no muscle aches.|no generalized muscle pain.|no neck pain.|back pain.|joint pain.|muscle aches.|generalized mucle pain.|neck pain."][text name="ros_msk" default=" "]
-Skin: [checkbox name="ros_skin_check" value="no rash.|no bruising.|no lesions.|no itching.|rash.|bruising.|lesions.|itching."][text name="ros_skin" default=" "]
-Neuro: [checkbox name="ros_neuro_check" value="no headache.|no dizziness.|no syncope.|no loss of consciousness.|headache.|dizziness.|syncope.|loss of consciousness."][text name="ros_neuro" default=" "]
-Psych: [checkbox name="ros_psych_check" value="denies Suicide ideation/homicide ideation.|No hallucination.|No depression.|no anxiety.|Suicide ideation\homicide ideation.|hallucinations.|depressed.|anxious."][text name="ros_psych" default=" "]
-Endocrine: [checkbox name="ros_endo_check" value="no heat/cold intolerance.|no excessive thirst.|no polyuria.|heat intolerance.|cold intolerance.|excessive thirst.|polyuria"][text name="ros_endo" default=" "]
-Hematologic: [checkbox name="ros_heme_check" value="no excessive bruising.|no excessive bleeding.|excessive bruising.|excessive bleeding."][text name="ros_heme" default=" "]
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PHYSICAL EXAM
-Blood Pressure:[text name="pe_bp" default=" "]
-Pulse:[text name="pe_pulse" default=" "]
-SPO2:[text name="pe_spo2" default=" "]
-CO2:[text name="CO2" default=" "]
-BGL:[text name="pe_bgl" default=" "]
-EKG FINDINGSs: [checkbox name="EKG" value="Sinus Rhythm.|Sinus Bradycardia.|Sinus Tachycardia.|Sinus Arrhythmia.|Wandering Atrial Pacemaker.|Multifocal ATach.|AFIB.|AFIB w/RVR.|Supraventricular Tachycardia.|Aflutter.|Junctional Rhythm.|First Degree AV Block.|Second Degree Type 1.|Second Degree Type 2.|3rd Degree Block.|IVR.|Accelerated IVR.|VTach.|VFib.|Asytole.|PEA.|Torsades.|w/PVC's.|w/PAC's.|w/PJC's."][text name="ros_heme" default=" "]
-12 LEAD FINDINGS: [text name="CC" size = 45 default=" "]
-GENERAL: [checkbox name="pe_general_check" value="Well developed/well nourished.|Well appearing.|in no acute distresss.|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|ears patent.|no bleeding.|bleeding.|positive HALO test.|negative HALO test.|dry mucous membranes.|extra salivation. |normal mucous.|normal pharynx.|no trauma to mouth.|trauma to face.|trauma to mouth."][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.|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.|wheezing.|upper respiratory congestion."][text name="pe_resp" default=" "]
-GI:[checkbox name="pe_gi_check" value="atrumatic.|BS present in all 4 quadrants.|abdomen soft/nontender to palpation.|nondistended.|No rigidity.|no guarding.|no masses."][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.|abnormal range of motion.|pain on palpation.|strength not present in all extremities.|"][text name="pe_msk" default=" "]
-SKIN: [checkbox name="pe_skin_check" value="no rash.|no lesion.|no discoloration.|pink.|warm.|dry.|pale.|cool.|cyanotic.|flushed.|clammy.|hot."][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 slured.|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.|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.|tenderness/masses.|bruising.|bleeding."][text name="pe_heme" default=" "]
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PRIMARY IMPRESSION: [text name="PI" size = 55 default=" "]

SECONDARY IMPRESSION: [text name="SI" size = 55 default=" "]
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TREATMENT:[textarea name="Treatment" default=" "]
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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 closest ER.|Transported to Trauma Center."][text name="pe_trans" default=" "]

HOSPITAL NOTIFICATIONS:[checkbox name="notifications" value="CMED radio report|Milford|MWMC Framinghham|BI-Needham|Newton Wellesley|"]

REPORT/SIGNATURES: [checkbox name="pe_rep_check" value="Verbal report to receiving hospital|Signature obtained for transfer of care|Belongings left with nurse.||"][text name="pe_rep" default=" "]

PROVIDER WRITING REPORT: Jason Wilson-NREMT-P, Millis Fire Rescue