Narrative Test 2
Responding Unit(s):[checkbox name="DAS" value="SQ1|A1|A3|A4|A5|A6"] Dispatch Info:[textarea name="dispatch" default=" "] Response: [checkbox name="RESPONSE" value="emergent|nonemergent|lights + sirens|lights only|no lights or sirens|upgraded to emergent|downgraded to nonemergent"][text name="RESPONSE" default=" "] Upon our arrival,:[textarea name="arrived" default=" "] Chief Complaint:[text name="CC" size = 55 default=" "] Associated S/Sx[text name="Associated S/Sx" default=" "] History of Present Illness/Injury:[textarea name="HX_OF_PRESENT_ILLNESS" default=" "] PMH: see "history" section Allergies: see "history" section Primary: Airway: [checkbox name="airway" value="airway open|airway patent|no airway obstructions|airway positioned to open|airway not patent|obstructions to airway|requires airway adjunct|requires advanced airway|requires positive pressure ventilation"][text name="airway" default=" "] Breathing: [checkbox name="breathing" value="breathing spontaneously|breathing regularly|respirations adequate|equal and symmetrical chest rise|no increased work of breathing|no accessory muscle use|no nasal flaring|no tripoding|no apparent life threats to breathing|apneic|eupneic|hypoventilating|hyperventilating|irregular respirations|inadequate respirations|inadequate depth|asymmetrical chest rise|increased work of breathing| accessory muscle use|nasal flaring|tripoding|apparent life threats to breathing"][text name="breathing" default=" "] Circulation: [checkbox name="circulation" value="no obvious bleeding|radial pulses palpable bilaterally|radial pulses +1 BL|radial pulses +2 BL|radial pulses +3 BL|radial pulses +4 BL|skin color appropriate|capillary refill <2 seconds|no apparent life treats to circulation|active bleeding|hemorrhage controlled|tq applied|pulses not palpable|skin color not appropriate|capillary refill >2 seconds|life threatening concerns with circulation"][text name="ros_constitutional" default=" "] Mental Status/LOC: [checkbox name="Mental Status/LOC" value="alert|responsive to verbal stimuli|responsive to painful stimuli|unresponsive|oriented to|person|place|time|situation|disoriented to|person|place|time|situation"][text name="ros_constitutional" default=" "] GCS Eye: Verbal: Motor: Total: Review of Systems: -Constitutional: [checkbox name="ros_constitutional_check" value="no fever.|no chills.|no weakness.|no fatigue.|no malaise.|fever.|chills.|weakness.|malaise."][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.|Normal.|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.|Normal.|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.|Normal.|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.|Normal.|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.|Normal.|back pain.|joint pain.|muscle aches.|generalized muscle pain.|neck pain."][text name="ros_msk" default=" "] -Skin: [checkbox name="ros_skin_check" value="no rash.|no bruising.|no lesions.|no itching.|Normal.|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.|Normal.|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.|Normal.|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.|Normal.|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.|Normal.|excessive bruising.|excessive bleeding."][text name="ros_heme" 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|ears patent.|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."][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=" "] -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=" "] TREATMENT:[textarea name="Treatment" default=" "] Refusal: Despite multiple attempts by myself and my partner to convince the patient (and/or responsible party) to be transported to the hospital for further evaluation and treatment, the patient remains adamant that they do not want to go. The patient/guardian is oriented, clear of mind, and has the capacity to understand the presented information. This patient/guardian has verbalized full understanding of their symptoms, and understand that forgoing further evaluation and/or treatment could pose a significant medical risk to the patient's life. The patient/guardian has verbalized that they understand our treatment plan, including interventions and transport destination, and does not want these interventions at this time. Furthermore, the patient/guardian acknowledges that forgoing this treatment could lead to worsening of condition up to and including death. The patient/guardian understands that they are free to call 911 should the patient's condition worsen, or they later decide that they wish to be transported to the Emergency Department for further evaluation and intervention. EMS also ensured that the patient/guardian was aware of other resources available such as contacting their Primary Care Provider, or visiting Urgent Care or Emergency Department on their own. The patient/guardian acknowledged these resources. 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 SRM 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=" "] Nurse/Physician:[text name="Nurse" size = 55 default=" "] Signatures: [checkbox name="pe_rep_check" value="obtained from patient|obtained from guardian/POA|not obtained from patient|unable to sign|no representative available.|Nurse signed as witness."][text name="pe_rep" default=" "] Provider writing report:[text name="RW" default=" "]
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Sandbox Metrics: Structured Data Index 0.42, 73 form elements, 280 boilerplate words, 38 text boxes, 4 text areas, 31 checkboxes, 359 total clicks
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