SEMS JAN 2023 UPDATED PCR

TRUCK NUMBER:[checkbox name="TRUCK_NUMBER" value="801|802|803|804|805|806|807|808|809|810|ALS|BLS"]
DISPATCHED TO:[checkbox name="DISPATCHED_TO" value="ABD PAIN| CARDIAC| CARDIAC ARREST| DIFF BREATH| PSYCH| MATERNITY|MEDICAL ALARM| MVA| SICK|TRAUMA|UNRESPONSIVE| FALL|LIFT ASSIST| SI/HI| UNKNOWN"]
PRIORITY[checkbox name="PRIORITY" value="EMERGENT| LIGHTS/SIRENS| LIGHTS NO SIRENS| NONEMERGENT| NO LIGHTS NO SIRENS| WITH DISPATCH INSTRUCTING TO STAGE FOR PD| UPGRADED TO EMERGENT| DOWNGRADED TO NONEMERGENT| PER DISPATCH"]
************************************************
COVID-19 QUESTIONS:
CLOSE CONTACT WITH PERSON WITH CONFIRMED OR SUSPECTED COVID-19:[select name="CONTACT_COVID" value="NO|YES"] 
TRAVEL TO HIGH RISK COVID-19 AREAS PER CURRENT LOCAL GUIDANCE:[select name="TRAVEL_COVID" value="NO|YES"]
************************************************

SCENE TYPE:[checkbox name="SCENE_TYPE" value="HOME| ASSISTED LIVING FACILITY| BUSINESS| GOV FAC| PARKING LOT| ROADWAY| SCHOOL| N/A"] 
SCENE APPEARED:[checkbox name="SCENE_APPEARED" value="WELL KEPT/CLEAN| IN DISARRAY| N/A"]

PT LOCATED: [checkbox name="PT_LOCATED" value="IN LR| IN KITCHEN|IN BEDROOM|IN ASSIGNED ROOM| IN HOLDING CELL| IN FRONT YARD| IN BACK YARD| OUTSIDE| ON ROADWAY| ON SIDEWALK| N/A"]
PT APPEARED: [checkbox name="PT_APPEARED" value=" GCS| 15| 14| 13| <13| BASELINE| ACCORDING TO| FAMILY| STAFF| AIDE| BYSTANDERS| AOX| 1| 2| 3| 4| PLACE| EVENT| TIME| PERSON| MONEY| UNATTAINABLE| UNCOOPERATIVE| BASELINE| N/A"]
PT PRESENTATION ON SCENE:[checkbox name="PT_PRESENTATION" value="PT| AMBULATING| AND| TALKING| YELLING| SMOKING A CIGARETTE| TO| SITTING| STUMBLING| LAYING DOWN| SUPINE| LAYING ON L-SIDE| LAYING ON R-SIDE| ON GROUND| ON BED| ON SOFA| ON CHAIR| ON SIDEWALK| ON ROADWAY|IN WHEELCHAIR| PD| FD| FAMILY| BYSTANDERS| AIDE| PT UNRESPONSIVE| CREW REQUESTED ALS| N/A"]

OTHERS ON SCENE: [checkbox name="OTHERS_ONSCENE" value="800 ON SCENE | PTA OF EMS| SAME TIME AS EMS| AFTER ARRIVAL OF EMS | PD ON SCENE|FD ON SCENE| ARRIVAL SAME TIME AS EMS| PTA OF EMS| AFTER ARRIVAL OF EMS| BYSTANDERS| CHILDREN| HOME HEALTH AIDE| FAMILY| SPOUSE| STAFF| ON SCENE|  STANDING| SITTING| IN VICINITY OF PT| OUTSIDE| OF RESIDENCE| OF SCENE| ON SCENE| INSIDE OF| PTS ROOM| AT STAFF DESK| NO OTHERS ON SCENE"]

PT STATES CHIEF COMPLAINT OF:[text name="CC" default="CC"]
STARTING: [checkbox name="CC_STARTING" value="PT STATED CC| PAIN |RATING IT | 1| 2| 3| 4| 5| 6| 7| 8| 9| 10| OUT OF 10| ANXIETY| CRAMPS|  HTN|  +N|+V|+D|-N|-V|-D| SOB| WEAKNESS| DENIED ANY CC| STARTING| TODAY| YESTERDAY| +1| +2| +3| DAYS(S)| WEEK(S)| PT| STATED| DENIED| TAKING| RX| OTC| MEDS| WITH PT STATING| TEMP RELIEF| NO RELIEF| NO ACCESS TO MEDICATION| PT HAS| PT HAS NOT HAD| SIM CC PRIOR|N/A"]
PMHX: NOTED IN REQUIRED AREA
ALLERGIES: NOTED IN REQUIRED AREA

GENERAL PT APPEARANCE: [checkbox name="GENERAL_APPEARANCE" value="WELL DEVELOPED/WELL NOURISHED| WELL APPEARING| IN NO ACUTE DISTRESS| MALNOURISHED|IN ACUTE DISTRESS| OBESE| NOTED TO HAVE POSSIBLE BIOHAZARDS ON HANDS/BODY| N/A"]

PAIN: [checkbox name="PAIN" value="DENIES PAIN| FEELING PAIN| IN OR AROUND| URQ| LRQ| ULQ| LLQ| IN OR AROUND NAVEL| ABDOMEN| RIGHT FLANK| LEFT FLANK| HEAD| NECK| LOWER| MID| UPPER|BACK| DESCRIBING IT AS| MILD| MODERATE| SEVERE| SHARP| DULL| ACHING| INTERMIT| CONSTANT| RADIATING| DENIYING ANY RADIATING| NON| REPRODUCIBLE | RATING PAIN ON SCALE OF| 1| 2| 3| 4| 5| 6| 7| 8| 9| 10| OUT OF 10"]

INITIAL ABC'S:

AIRWAY: [checkbox name="AIRWAY" value="NORMAL| AIRWAY OPEN| AIRWAY PATENT| NO AIRWAY OBSTRUCTIONS| AIRWAY POSITIONED TO OPEN| AIRWAY NOT PATENT| OBSTRUCTIONS TO AIRWAY| REQUIRES AIRWAY ADJUNCT| REQUIRES ADVANCED AIRWAY| REQUIRES ARTIFICIAL VENTILATION| PT STATES SOB| PT DENIES SOB| PT RX INHALER DEPENDANT|PTN|N/A"]

O2: [checkbox name="O2" value="ON O2 AT BASELINE| NO O2 PROVIDED AS PT. WAS ADEQUATELY BREATHING| PTN| PLACED PT. ON 02| VIA|NC|NRB|2|4|6|10|NO CHANGE IN PT. CONDITION| IMPROVEMENT IN PT. CONDITION|N/A"]

BREATHING: [checkbox name="BREATHING" value="NORMAL| BREATHING SPONTANEOUSLY| BREATHING REGULAR| ADEQUATE RESPIRATIONS| APPROPRIATE TIDAL VOLUME| NOT SPONTANEOUSLY BREATHING| IRREGULAR RESPIRATIONS| INADEQUATE RESPIRATIONS| INADEQUATE TIDAL VOLUME|N/A"]

CIRCULATION: [checkbox name="CIRCULATION" value="NORMAL| NO OBVIOUS BLEEDING| PULSES INTACT| SKIN COLOR APPROPRIATE| NO LIFE THREATS TO CIRCULATION| HEMORRHAGE PRESENT| HEMORRHAGE CONTROLLED| ARTERIAL TOURNIQUET APPLIED| TO UPPER L-EXT| TO UPPER R-EXT| TO LOWER L-EXT| TO LOWER R-EXT| PULSES NOT INTACT| CYANOSIS NOTED IN EXTREMITIES | NO CYANOSIS NOTED IN EXTREMITIES | SKIN COLOR NOT APPROPRIATE| LIFE THREATENING CONCERNS WITH CIRCULATION| RADIAL PULSE PALPATED| ON R-SIDE| ON L-SIDE| NOTED TO BE| STRONG| WEAK| THREADY| REG| IRR| N/A"]

REVIEW OF SYSTEMS:

CONSTITUTIONAL: [checkbox name="CONSTITU" value="NORMAL| NO FEVER| NO CHILLS| NO WEAKNESS| NO FATIGUE| FEVER| CHILLS| WEAKNESS| PT| STAFF| STATES| ACUTE ONSET| CHRONIC| PT FEBRILE TO TOUCH| N/A"]

HEENT: [checkbox name="HEENT" value="NORMAL| NO VISION CHANGES| NO EAR PAIN| NO NASAL CONGESTION| NO SORE THROAT| NO COUGH| ATRAUMATIC| NO RINGING IN THE EARS| PERRLA| WHITE SCLERA| CONJUNCTIVA PINK/RED| EARS PATENT| NO BLEEDING| BLEEDING| CONTROLLED| UNCONTROLLED| DRY MUCOUS MEMBRANES| EXTRA SALIVATION| NORMAL MUCOUS| NORMAL PHARYNX| NO TRAUMA TO MOUTH| NO TRAUMA TO EARS| NO TRAUMA TO TOUNGE| TRAUMA TO TOUNGE| TRAUMA TO FACE| TRAUMA TO MOUTH| N/A"]

CARDIOVASCULAR: [checkbox name="CARDIOVAS" value="NORMAL| NO CHEST PAIN|NO PALPITATIONS| NO SWELLING OF EXTREMITIES| CHEST PAIN|PALPITATIONS| PAIN IN CHEST| MUSCULAR NATURE| CARDIAC NATURE| MID STERNUM| ON L-SIDE| ON R-SIDE| SWELLING OF EXTREMITIES| NOTED IN HANDS| NOTED IN FEET| KNOWN| ACUTE| CHRONIC|RECORDED VIA| PALPATED| REGULAR RATE AND RHYTHM| -JVD| - EDEMA| PERIPHERAL PULSES INTACT| - CYANOSIS| IRREGULAR RATE| JVD PRESENT| EDEMA PRESENT| NO PERIPHERAL PULSES| CYANOSIS PRESENT| BLEEDING| N/A"]

RESPIRATORY:[checkbox name="RESPIRATORY" value="NORMAL| - SOB| - HEMOPTYSIS| - DYSPNEA| SHORTNESS OF BREATH| HEMOPTYSIS| DYSPNEA|CLEAR TO AUSCULTATION BILATERALLY| NO RALES, RHONCHI, WHEEZES| NO RETRACTIONS| NO ACCESSORY MUSCLE USE| NO STRIDOR| WHEEZING| STRIDOR| RALES|HX UPPER RESPIRATORY CONGESTION| HX OF NEB USE| USED RX NEB PTA OF EMS| N/A| NOTED IN| URL| ULL| LLL|LRL"]

GI:[checkbox name="GI" value="NORMAL| NO CHANGE IN APPETITE| NO ABDOMINAL PAIN| NO HEMATEMESIS| CHANGE IN APPETITE| NO N/V/D| ABDOMINAL PAIN| HEMATEMESIS| NAUSEA| VOMITING| DIARRHEA| POOR PO INTAKE| NORMAL PO INTAKE| PER FAMILY| PER STAFF|ATRAUMATIC.| BS PRESENT |ABDOMEN SOFT/NON-TENDER TO PALPATION| NON-DISTENDED|NO RIGIDITY| NO GUARDING| NO MASSES| NORMAL| PT STATED CRAMPING| TRAUMA PRESENT| TENDER ABDOMEN| RIGID ABDOMEN| DISTENDED ABDOMEN| GUARDING PRESENT| MASSES PRESENT| N/A"]

GU: [checkbox name="GU" value="NORMAL| NO URINARY FREQUENCY| NO URINARY URGENCY| NO DYSURIA| NO HEMATURIA| NO CHANGE IN COLOR OR SMELL| NO LEAKAGE OF URINE| URINARY CATHETER| FOUL SMELL NOTED BY EMS| PT HAS URINARY CATHETER| CLOUDY CONTENT NOTED AT URINE COLLECTION SITE| URINARY FREQUENCY| URINARY URGENCY| DYSURIA| HEMATURIA| LEAKAGE OF URINE| PT INCONTINENT| PTA| U/A| OF EMS| HX OF UTI| N/A"]

MUSCULOSKELETAL: [checkbox name="MUSCULOSKELETAL" value="NORMAL RANGE OF MOTION| BASELINE| WITHOUT PAIN ON PALPATION|+PMS| NO CREPITUS| NO OBVIOUS DEFORMITY| STRENGTH AGE APPROPRIATE| ABNORMAL RANGE OF MOTION| PAIN ON PALPATION| STRENGTH NOT PRESENT| CREPITUS| CONTRACTURES PRESENT| ASTHENIA| OBVIOUS DEFORMITY| IN ALL EXTREMITIES| LEFT UPPER EXTREMITY| RIGHT UPPER EXTREMITY| LEFT LOWER EXTREMITY| RIGHT LOWER EXTREMITY| DENIES - NECK PAIN, GENERALIZED JOINT PAIN| GENERALIZED| MUSCLE PAIN| ACHES/CRAMPS| WEAKNESS| PT| BASELINE| AFFIRMS -| NECK PAIN| SHOULDER PAIN| GENERALIZED JOINT PAIN| GENERALIZED MUSCLE ACHES| GENERALIZED MUSCLE PAIN| GENERALIZED MUSCLE CRAMPS| GENERALIZED MUSCLE WEAKNESS| CONTRACTURES PRESENT| ASTHENIA| DID NOT ASSESS| UNABLE TO ASSESS| UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE| UNABLE TO ASSESS DUE TO UNCOOPERATIVE STATE| N/A"]

SKIN: [checkbox name="SKIN" value="NO RASHES, SKIN TEARS, SWELLING, LESIONS, OR DISCOLORATION| PINK, WARM, AND DRY, W/ GOOD TURGOR| GOOD TURGOR|PINK|DRY|PALE|COOL|CYANOTIC|FLUSHED|CLAMMY|HOT|WARM|DIAPHORETIC|LIVIDITY|MOTTLING| JAUNDICED| SKIN TEAR| SWELLING| POOR SKIN TURGOR| EXCESSIVELY DRY SKIN| EMS NOTED| DENIES - SKIN PAIN, NUMBNESS, TINGLING, DISCOLORATION, SWELLING, RASH, BRUISING, LESIONS, SKIN BREAKS, SENSITIVITY OR ITCHING| AFFIRMS| RASH| BRUISING| LESIONS| SKIN PAIN| NUMBNESS| TINGLING| DISCOLORATION| SENSITIVITY| SWELLING| SKIN BREAKS| ITCHING| UNKEPT/DIRTY| UNABLE TO ASSESS DUE TO ALTERED MENTAL STATE| UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE| N/A"]

NEURO: [checkbox name="NEURO" value="GROSSLY ORIENTED X 4, GAIT STEADY & BALANCED, SENSATION INTACT WITH NORMAL REFLEXES, SMILE SYMMETRICAL, AND SPEECH NOT SLURRED| GROSSLY ORIENTED TO BASELINE| CONFIRMED BY| STAFF| FAMILY| BYSTANDERS| AIDE| NEURO NOT GROSSLY INTACT| APHAGIA| APHASIA| DECEREBRATE POSTURING| DECORTICATE POSTURING| SEIZURE ACTIVITY| STRENGTH ASYMMETRICAL| GAIT ABNORMAL| SENSATION ABSENT| NO REFLEXES| SMILE ASYMMETRICAL| HEMIPLEGIA| HEMIPARESIS| SLURRED SPEECH| OBTUNDED| DENIES - HEADACHE, DIZZINESS, SYNCOPE, NUMBNESS/TINGLING, SEIZURES OR OTHERWISE LOSS OF CONSCIOUSNESS| DENIES FOCAL DEFICITS| AFFIRMS -|FOCAL DEFICITS| INCOORDINATION| MEMORY DEFICITS|HEADACHE|DIZZINESS|OBTUNDED|SYNCOPE|NUMBNESS/TINGLING|LOSS OF CONSCIOUSNESS| DID NOT ASSESS| UNABLE TO ASSESS| UNABLE TO ASSESS ACCURATELY DUE TO ALTERED MENTAL STATE| UNABLE TO ASSESS DUE TO UNCOOPERATIVE STATE| LAST KNOWN WELL TIME|>24HRS|<24HRS|PT|HAS|DOES NOT HAVE PAST CVA HX| PT NON ENGLISH SPEAKING| PT NON VERBAL AT BASELINE| N/A"]

PSYCH: [checkbox name="PSYCH" value="NORMAL|DENIES SUICIDAL/HOMICIDAL IDEATIONS|NO HALLUCINATIONS|NO DEPRESSION|NO ANXIETY|SUICIDA/HOMICIDAL IDEATIONS|HALLUCINATIONS|AUDIO|VISUAL|DEPRESSED|ANXIOUS|CRYING|IN EMOTIONAL STATE|UNCOOPERATIVE|NON ENGLISH SPEAKING|PT HX OF DEMENTIA| PT CHOSE TO REMAIN SILENT|PT WISHED NOT TO DISCUSS EVENTS WITH EMS PROVIDER|PLEASANT, CALM, AND COOPERATIVE|JUDGEMENT AND INSIGHT INTACT|HAS A PLAN MADE|PSYCH AT BASELINE|UNDERSTANDS TREATMENT|THOUGHT PROCESS NORMAL|NORMAL AFFECT|UNPLEASANT|NOT CALM|UNCOOPERATIVE|DOES NOT HAVE A PLAN|DOES NOT UNDERSTAND TREATMENT| PRIOR HX OF PSYCH| PT. HX OF DEMENTIA| PT IS NON VERBAL| N/A"]

ENDOCRINE: [checkbox name="ENDOCRINE" value="NORMAL|NO HEAT/COLD INTOLERANCE|NO EXCESSIVE THIRST|NO POLYURIA|HEAT INTOLERANCE|COLD INTOLERANCE|EXCESSIVE THIRST|POLYURIA| N/A"]

HEMATOLOGIC: [checkbox name="HEMATOLOGIC" value="NORMAL|NO EXCESSIVE BRUISING|NO EXCESSIVE BLEEDING|EXCESSIVE BRUISING|EXCESSIVE BLEEDING|NO TENDERNESS OR MASSES PALPATED|NO BRUISES|NO BLEEDING|TENDERNESS|BRUISING|BLEEDING| N/A"]

[checkbox name="TRANSPORT" value="PT REQUESTED EVALUATION AT ED|NO TRANSPORT PROVIDED AS PT REFUSED/RMA|PATIENT REFUSED TRANSPORT|AMA/RMA|PATIENT BLS TREATED AND RELEASED|NO TRANSPORT|LIFT ASSIST ONLY| N/A"] 

[checkbox name="WHAT_HOSPITAL_CHOICE" value="AT BPT ED|AT STVMC|AT GRIFFIN| AT YALE| AT VA| NO TRANSPORT| N/A"]

[checkbox name="PT_TO_STRETCHER" value="SECURED TO STRETCHER|W ALL AVAILABLE STRAPS| PT. PLACED ON STRETCHER USING LIFT AND CARRY TECHNIQUES| PLACED IN STAIR CHAIR, THEN STRETCHER| W/O ASSISTANCE| W/ ASSISTANCE| W/O INCIDENT OR EXPRESSION OF PAIN/DISCOMFORT| W/ PAIN/DISCOMFORT EXPRESSED| PATIENT SECURED TO THE STRETCHER WITH ALL RAILS AND STRAPS| IN SUPINE POSITION| IN SEMI-FOWLERS POSITION| IN FOWLERS POSITION| SITTING| LOADED IN TO AMBULANCE FOR TRANSPORT W/O ISSUE| WITH FD ASSISTANCE| WITH PD ASSISTANCE| PT BELONGINGS| PERSONAL BAG| CELL PHONE| PERSONAL ITEMS| PLACED IN REAR OF STRETCHER| REMAINED WITH PT FOR DURATION OF TRANSPORT| PT DID NOT BRING ANY PERSONAL BELONGINGS| LOADED FOR TRANSPORT| PT O2 MOVED FROM MOBILE TANK TO STRETCHER TANK| N/A"]

[checkbox name="TRANSPORT_PRIORITY" value="EMERGENCY|NON EMERGENCY|EMERGENCY DOWNGRADED TO NON EMERGENCY|NON EMERGENCY UPGRADED TO EMERGENCY| NO TRANSPORT| N/A"]

[checkbox name="WHAT_HOSPITAL_TRANSPORT" value="TRANSPORTED TO STVMC ED|TRANSPORTED TO GRIFFIN| TRANSPORTED TO VA| TRANSPORTED TO BPT ED|TRANSPORTED TO YALE ED|VIA BLS|NO PATCH NEEDED|TWIAGE APP USED| TWIAGE APP UNAVILABLE RADIO PATCH PROVIDED| NO TRANSPORT| N/A"]

[checkbox name="ED_ARRIVAL" value="
ARRIVAL AT ED| PT. ABLE TO AMBULATE FROM STRETCHER TO ED COT VIA TURN AND PIVOT WITH EMS ASSISTANCE| PT. MOVED FROM STRETCHER TO ED COT VIA DRAWSHEET| AMBULATED FROM STRETCHER TO WHEELCHAIR| W/O ASSISTANCE| W/ ASSISTANCE| W/O INCIDENT| BELONGINGS| PLACED IN PT. CARE| PLACED ON TABLE| PLACED IN CARE OF RN| PT O2 MOVED FROM STRETCHER TANK TO ROOM SUPPLY| N/A"]

[checkbox name="REPORT_TO" value="VERBAL REPORT TO| NURSE| DR| PT LEFT IN WAITING AREA, VIA WHEELCHAIR, PER TRIAGE RN|IMPROVEMENT IN PATIENT CONDITION|DECLINE IN PATIENT CONDITION|NO CHANGE IN PATIENT CONDITION| N/A"]

SIGNATURES: [checkbox name="SIGNATURE" value="OBTAINED FROM PATIENT| OBTAINED FROM GUARDIAN/POA| OBTAINED FROM RESPONSIBLE PARTY| PATIENT REFUSED TO SIGN| PATIENT UNABLE TO SIGN| OBTAINED FROM LAW ENFORCEMENT| OBTAINED FROM NURSE/STAFF| EMS CREW SIGNED| WITNESS SIGNED| NURSE SIGNED FOR PATIENT| UNABLE TO OBTAIN SIGNATURES DUE TO EQUIPMENT FAILURE| SECURED HOSPITAL FACE SHEET| N/A"]

DELAYS: [checkbox name="DELAY" value="NO DELAY| DELAY DUE TO LOCATION OF SCENE| DELAY DUE TO EXTRICATION TIME| DELAY DUE TO PT. CARE TRANSFER IN ED (OVERCROWDING)|DELAY DUE TO PT. EXTRICATION| ADVISED DISPATCH| N/A"]

[checkbox name="REFUSE_AMA" value="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"]

ANY QUOTES IN PCR ARE FROM MEMORY.






TRUCK NUMBER:
DISPATCHED TO:
PRIORITY
************************************************
COVID-19 QUESTIONS:
CLOSE CONTACT WITH PERSON WITH CONFIRMED OR SUSPECTED COVID-19:
TRAVEL TO HIGH RISK COVID-19 AREAS PER CURRENT LOCAL GUIDANCE:
************************************************

SCENE TYPE:
SCENE APPEARED:

PT LOCATED:
PT APPEARED:
PT PRESENTATION ON SCENE:

OTHERS ON SCENE:

PT STATES CHIEF COMPLAINT OF:
STARTING:
PMHX: NOTED IN REQUIRED AREA
ALLERGIES: NOTED IN REQUIRED AREA

GENERAL PT APPEARANCE:

PAIN:

INITIAL ABC'S:

AIRWAY:

O2:

BREATHING:

CIRCULATION:

REVIEW OF SYSTEMS:

CONSTITUTIONAL:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GI:

GU:

MUSCULOSKELETAL:

SKIN:

NEURO:

PSYCH:

ENDOCRINE:

HEMATOLOGIC:















SIGNATURES:

DELAYS:



ANY QUOTES IN PCR ARE FROM MEMORY.






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