FVAMC EAS

Dispatched for:[text name="variable_1" default=" "]yo [select name="variable_2" value="M|F"] PT transport to [select name="variable_5" value="the hospital|Cape Fear Valley Medical Center|UNC REX Healthcare|UNC Memorial Hospital|Duke Medical Center|Durham VA Medical Center|UNC Southeastern Medical Center|Womack Army Medical Center"] due to [text name="variable_6" default=" "].
[select name="variable_7" value="Negative|Positive|Undetermined|inconclusive"] PUI.

All EMS personnel wore appropriate PPE before making contact with PT.[checkbox name="variable_8" value="Nurse states:|Family states:|Friend states:|EMS states:| Bystander states:"]
[textarea name="variable_9" default=" "]
[checkbox name="variable_34" value="Scene size up:"]
[textarea name="variable_35" default=" "]
[checkbox name="variable_1000" value="Pt has not had  a fever, chills, cough, shortness of breath/difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste/smell, sore throat, congestion/runny nose, nausea/vomiting, diarrhea, or contact with possible COVID 19. Pt vaccinated for COVID 19."]
 
Found PT [select name="variable_36" value="semi-fowler's|supine|prone|right lateral|left lateral|sitting"] [checkbox name="variable_37" value="in chair|in recliner|in bed|on edge of bed|on floor|on the ground|on the couch|on the toilet|in shower"]
PT dressed [checkbox name="variable_38" value="fully.|in hospital gown.|appropriate for the weather."]
[select name="variable_39" value=" |Applied face mask to PT|PT wearing face mask."]
[checkbox name="variable_40" value="PT has: "][checkbox name="variable_41" value="foley cath|g IV in|pacemaker|no implanted devices"]
[checkbox name="variable_42" value="PT alert "][checkbox name="variable_43" value="by verbal|by pain|Pt unresponsive"] [checkbox name="variable_44" value="PT oriented "][checkbox name="variable_45" value="Person|Place|Time|Event|Mental status is baseline"].
Breathing: [select name="variable_46" value="Regular|Irregular||Fast|Slow|Apneic"]. [checkbox name="variable_47" value="Non-labored|Labored|deep|Shallow"]. Pulse [select name="variable_48" value="Regular|Irregular||Tachycardic|Bradycardic|Pulseless"], [select name="variable_49" value="Strong|Weak"],  Skin [select name="variable_50" value="Pink|Pale|Ashen|Cyanotic|Flush|Jaundiced|has lividity"], [select name="variable_51" value="Warm|Hot|Cool|Cold"], [select name="variable_52" value="Dry|Clammy|Diaphoretic"] with [select name="variable_53" value="good|poor"] skin turgor.  Neuro [checkbox name="variable_54" value="intact|unable to assess."] [checkbox name="variable_55" value="with general weakness."] [checkbox name="variable_56" value="Negative for"] Pain [select name="variable_57" value=" |1 of 10|2 of 10|3 of 10|4 of 10|5 of 10|6 of 10|7 of 10|8 of 10|9 of 10|10 of 10"].
  
[checkbox name="variable_58" value="Pt states:"][textarea name="variable_59" default=" "]
 
[checkbox name="variable_60" value="PT denies: "] [checkbox name="variable_61" value="N/V/D|Dizziness|Headache|Chest discomfort"]. [checkbox name="variable_62" value="PT able to take a deep breath "] [select name="variable_63" value=" |without difficulty|with difficulty|with pain"][checkbox name="variable_64" value="Assisted PT to stair chair, secured PT to stair chair with safety straps."]
[select name="variable_65" value="Sheet lifted PT|PT scooted himself/herself|Hover lifted Pt|Pt walked with assistance|Pt walked without assistance|PT stood and pivoted without assistance|Pt stood and pivoted with assistance"] to the stretcher.  Covered PT with a blanket.  PT [select name="variable_66" value="semi-Fowler’s|supine|right lateral|left lateral"].  Secured PT to stretcher with safety straps.  Stretcher to the truck.[checkbox name="variable_67" value="Pain:"]
[checkbox name="variable_68" value="Onset: "][text name="variable_69" default=" "]    
[checkbox name="variable_70" value="Provocation: "][text name="variable_71" default=" "]      
[checkbox name="variable_72" value="Quality: "][select name="variable_73" value=" |sharp|achy|disperse"][text name="variable_74" default=" "]    
[checkbox name="variable_75" value="radiate: "][text name="variable_76" default=" "]     
[checkbox name="variable_77" value="Severity: "][text name="variable_78" default=" "][checkbox name="variable_79" value="of 10"]
[checkbox name="variable_80" value="Time: "][text name="variable_81" default=" "][checkbox name="variable_93" value="Psyche:"] [checkbox name="variable_94" value="PT calm and cooperative|No drugs or alcohol|No SI/No Homicidal ideations|Drug use|ETOH|Pt safety ensured"][checkbox name="variable_95" value="Partner doffed PPE at the foot of the stretcher and returned to the cab."]
 
[select name="variable_96" value="Non-emergent|Emergent"] transport. [textarea name="variable_97" default=" "]
 
BLS interventions: 
Vitals as noted.
[checkbox name="variable_98" value="BGL|Aspirin via PO|Continued PT on O2 as stated above|lpm O2 via NC showing increase in SPO2|15lpm O2 via NRB showing improved change in CO level|15lpm O2 via BVM at 1 breath every 5-6sec showing improved change in CO level"]
     
ALS Interventions:
[checkbox name="variable_99" value="4-lead cardiac monitor|12-lead cardiac monitor|IV LOC successful.  No irritation was noted.  Flushed easily|IV lock unsuccessful|Nitro Tab via SL showing a decrease in pain to 10 of 10|Fentanyl via IVP showing a decrease in pain to 10 of 10|NS via IV gravity showing an increase in SBP|Zofran IVP showing a decrease in nausea|Continued Pt on as stated above|Normal Saline Bolus|none required"]
 
Changes en route:  No other significant findings. [textarea name="variable_114" default=" "]
 
[checkbox name="variable_108" value="Pt verbalized no complaints."][checkbox name="variable_109" value="Pt states: "] [textarea name="variable_110" default=" "]
 
Partner wore appropriate PPE before opening doors for the stretcher.
Stretcher to [select name="variable_5" value=" "][checkbox name="variable_2000" value=" Cape Fear Valley Medical Center|UNC REX Healthcare|UNC Memorial Hospital|Duke Medical Center|Durham VA Medical Center|UNC Southeastern Medical Center|Womaclk Army Medical Center "]. [select name="variable_111" value="Sheet lifted PT|Pt scooted Pt scooted himself/herself|Hover lifted PT|PT stood and pivoted without assistance|Pt stood and pivoted with assistance|PT scooted over|Pt walked unassisted|Pt walked with assistance"] to bed.  Settled PT into bed.
Gave report and transferred care to staff.
[checkbox name="variable_112" value="PT refused transport.  PT advised of the risks and to seek medical attention for any abnormal changes.  PT signed the refusal form.|Crew deconned entire pt compartment of the truck."]