Millis

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* COVID-19 SCREENING/PRECAUTIONS*
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[textarea name="variable_1" default="NONE"]
==========================================================
DISPATCHED TO: [textarea name="DISPATCHED TO" default=" "]

UPON ARRIVAL: [textarea name="UPON ARRIVAL" default=" "]
Age [text name="variable_1" default=" "]
Gender[checkbox name="Gender" value="Male|Female|Refused to Answer"]
CHIEF COMPLAINT: [text name="CC" default=" "]
HX OF PRESENT INJURY/ILLNESS
ONSET: [text name="O" size = 55 default=" "]
PROVOKING/RELIEVING FACTORS: [text name="P" size = 55 default=" "]
QUALITY/DESCRIBED AS: [text name="q" size = 55 default=" "]
AREA EFFECTED: [text name="r" size = 55 default=" "]
SEVERITY: [text name="s" size = 55 default=" "]
EVENTS LEADING UP TO ILLNESS/INJURY: [textarea name="e" size = 55 default=" "]

PRIOR MEDICAL HX: [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|Airway Patent|NO Airway obstructions|Airway positioned to open|Airway NOT Patent|Obstructions to airway|Airway adjunct REQUIRED|Advanced airway REQUIRED|Ventilation REQUIRED"][text name="airway" default=" "]

-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"][text name="breathing" default=" "]

-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|PULSES NOT INTACT|SKIN COLOR 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"][text name="consciousness" size = 55 default=" "]

VITAL SIGNS
-BLOOD PRESSURE: [text name="pe_bp" default=" "]
-PULSE: [text name="pe_pulse" default=" "]
-RESP: [text name="Resp" default=" "]
-SPO2: [text name="pe_spo2" default=" "]
-TEMP: [text name="TEMP" default=" "]
-BGL: [text name="pe_bgl" default=" "]
-EKG FINDINGS: [checkbox name="EKG" value="SINUS RHYTHM|SINUS BRADYCARDIA|SINUS TACHYCARDIA|SINUS ARRHYTHMIA|WANDERING ATRIAL PACEMAKER|MULTIFOCAL ATRIAL TACHYCARDIA|AFIB|AFIB W/RVR|SUPRAVENTRICULAR TACHYCARDIA|ATRIAL FLUTTER|JUNCTIONAL RHYTHM|FIRST DEGREE AV BLOCK|SECOND DEGREE TYPE 1|SECOND DEGREE TYPE 2|3RD DEGREE BLOCK|IVR|ACCELERATED IVR|VTach|VFIB|ASYSTOLE|PEA|TORSADES|W/PVC'S|W/PAC'S|W/PJC'S"][text name="ros_heme" default=" "]

PHYSICAL ASSESSMENT:

-GENERAL: [checkbox name="pe_general_check" value="WELL DEVELOPED, WELL NOURISHED, AND 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, NORMAL MUCOUS AND PHARYNX|NO BLEEDING, TRAUMA TO FACE OR MOUTH|BLEEDING|POSITIVE HALO TEST|NEGATIVE HALO TEST|DRY MUCOUS MEMBRANES|EXTRA SALIVATION|TRAUMA TO FACE|TRAUMA TO MOUTH"][text name="pe_heent" default=" "]
-CARDIOVASCULAR: [checkbox name="pe_cardio_check" value="REGULAR RATE AND RHYTHM WITHOUT ST ELEVATION, JUGULAR VEIN DISTENTION, OR EDEMA|PERIPHERAL PULSES INTACT, WITHOUT CYANOSIS|IRREGULAR RATE|IRREGULAR RHYTHM|ST ELEVATION PRESENT|JVD PRESENT|EDEMA PRESENT|NO PERIPHERAL PULSES|CYANOSIS PRESENT|BLEEDING"][text name="pe_cardio" default=" "]
-RESPIRATORY: [checkbox name="pe_resp_check" value="CLEAR TO AUSCULTATION BILATERALLY, NO RALES, RHONCHI, WHEEZES, STRIDOR, RETRACTIONS, OR ACCESSORY MUSCLE USE|WHEEZING|RALES|RHONCHI|STRIDOR|UPPER RESPIRATORY CONGESTION"][text name="pe_resp" default=" "]
-GI: [checkbox name="pe_gi_check" value="ATRAUMATIC, BOWEL SOUNDS PRESENT IN ALL 4 QUADRANTS, ABDOMEN SOFT/NON-TENDER TO PALPATION|NON-DISTENDED OR RIGID, NO GUARDING, NO MASSES|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 MOTION, WITHOUT PAIN ON PALPATION, AND STRENGTH 5/5 IN ALL EXTREMITIES|ABNORMAL RANGE OF MOTION|PAIN ON PALPATION|STRENGTH NOT PRESENT IN ALL EXTREMITIES|UNABLE TO ASSESS"][text name="pe_msk" default=" "]
-SKIN: [checkbox name="pe_skin_check" value="NO RASHES, LESIONS, DISCOLORATION, PINK, WARM, AND 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 WITH NORMAL REFLEXES, SMILE NORMAL, AND SPEECH NOT SLURRED|NEURO NOT GROSSLY INTACT|GAIT ABNORMAL|SENSATION ABSENT|NO REFLEXES|SMILE NOT SYMMETRICAL|SLURRED SPEECH|UNABLE TO ASSESS"][text name="pe_neuro" default=" "]
-PSYCH: [checkbox name="pe_psych_check" value="PLEASANT, CALM, AND COOPERATIVE, JUDGEMENT AND INSIGHT INTACT, UNDERSTANDS TREATMENT, THOUGHT PROCESS IN NORMAL WITH NORMAL EFFECT|HAS A PLAN MADE|UNPLEASANT|NOT CALM|UNCOOPERATIVE|DOES NOT HAVE A PLAN|DOES NOT UNDERSTAND TREATMENT|UNABLE TO ASSESS"][text name="pe_psych" default=" "]
-HEMATOLOGIC: [checkbox name="pe_heme_check" value="NO TENDERNESS OR MASSES PALPATED, NO BRUISES OR BLEEDING|TENDERNESS|BRUISING|BLEEDING|UNABLE TO ASSESS"][text name="pe_heme" default=" "]

TREATMENT: [checkbox name="treatment" value="Primary and secondary ALS assessment|Primary and secondary BLS assessment|Cardiac monitoring|IV access|Surgical mask on PT"] [textarea name="rxt" default=" "]

HOSPITAL NOTIFICATIONS: [checkbox name="pe_act_check" value="CMED radio report|STROKE Alert|TRAUMA Alert|STEMI Alert|HISTORIAN INFORMATION AND CONTACT NUMBER GATHERED|NO ALERTS ACTIVATED"][text name="pe_act" default=" "]

TRANSPORT: [checkbox name="pe_trans_check" value="STAIR CHAIR|ASSISTED TO STRETCHER|PT SECURED FOR EXTRICATION?/TRANSPORT WITH 5 POINT SAFETY RESTRAINT SYSTEM|TRANSFERRED INTO AMBULANCE FOR TRANSPORT|EMERGENCY|NON EMERGENCY|NON EMERGENCY UPGRADED TO EMERGENCY|PATIENT REFUSED TRANSPORT|AMA|PATIENT TREATED AND RELEASED|NO TRANSPORT|LIFT ASSIST ONLY|TRANSPORTED TO MRMC|TRANSPORTED TO METROWEST FRAMINGHAM|TRANSPORTED TO NEWTON WELLESLEY HOSPITAL|TRANSPORTED TO BI NEEDHAM"][text name="pe_trans" default=" "]

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

SIGNATURES: [checkbox name="SIGNATURE" value="OBTAINED FROM PATIENT|NOT OBTAINED FROM PATIENT|OBTAINED FROM GUARDIAN/POA|SIGNED BY LAW ENFORCEMENT AS GUARDIAN|UNABLE TO SIGN|NO REPRESENTATIVE AVAILABLE|NURSE SIGNED AS WITNESS|RECEIVING FACILITY REPRESENTATIVE"][text name="pe_SIG" default=" "]

[checkbox name="AMA" value="IN SPITE OF MULTIPLE ATTEMPTS BY MYSELF AND MY PARTNER TO CONVINCE THE PATIENT TO BE TRANSPORTED TO HOSPITAL FOR EVALUATION AND TREATMENT, WE HAVE UNFORTUNATELY BEEN UNSUCCESSFUL. HOWEVER, THE PATIENT HAS THE CAPACITY TO GIVE, RECEIVE, AND WITHHOLD INFORMATION. THE PATIENT VERBALIZES UNDERSTANDING OF THEIR CONDITION AND SYMPTOMS AND THAT REFUSING CARE COULD POSE SIGNIFICANT RISK TO THEIR LIFE. THE PATIENT HAS VERBALIZED TO ME THAT THEY UNDERSTAND OUR SPECIFIC TREATMENT PLAN WHICH INCLUDES TRANSPORT TO HOSPITAL, AND UNFORTUNATELY DOES NOT AGREE WITH US AND UNDERSTANDS WITHOUT THIS TREATMENT MAY CAUSE WORSENING OF CONDITION OR DEATH. THE PATIENT UNDERSTANDS THEY ARE FREE TO CALL 911 IF CONDITION WORSENS AND THEY FEEL THEY WISH TO BE TRANSPORTED TO EMERGENCY DEPARTMENT FOR FURTHER EVALUATION AND TREATMENT."]

REPORT WRITER: [checkbox name="pe_RW_check" value="Jason Wilson NREMT-P -Millis Fire/Rescue"][text name="RW" default=" "]
*********************************
* COVID-19 SCREENING/PRECAUTIONS*
*********************************

==========================================================
DISPATCHED TO:

UPON ARRIVAL:
Age
Gender
CHIEF COMPLAINT:
HX OF PRESENT INJURY/ILLNESS
ONSET:
PROVOKING/RELIEVING FACTORS:
QUALITY/DESCRIBED AS:
AREA EFFECTED:
SEVERITY:
EVENTS LEADING UP TO ILLNESS/INJURY:

PRIOR MEDICAL HX:

ALLERGIES:

INITIAL ABC's:
-AIRWAY:

-BREATHING:

-CIRCULATION:

LEVEL OF CONSCIOUSNESS:

VITAL SIGNS
-BLOOD PRESSURE:
-PULSE:
-RESP:
-SPO2:
-TEMP:
-BGL:
-EKG FINDINGS:

PHYSICAL ASSESSMENT:

-GENERAL:
-HEENT:
-CARDIOVASCULAR:
-RESPIRATORY:
-GI:
-MSK:
-SKIN:
-NEURO:
-PSYCH:
-HEMATOLOGIC:

TREATMENT:

HOSPITAL NOTIFICATIONS:

TRANSPORT:

REPORT:

SIGNATURES:



REPORT WRITER:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.38, 64 form elements, 75 boilerplate words, 33 text boxes, 7 text areas, 24 checkboxes, 222 total clicks
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