Procedure Performed. IV Placed / Checked / Removed
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1 Patient PMHx Full Name Portrait, 400x400 color, capture with a mobile device's onboard camera Is Bariatric? (appears as a warning to dispatchers and crews) Has DNR? (likewise) Requires Oxygen? (likewise) Height (metric or imperial) Weight (metric or imperial) Gender (picklist) Primary Race (picklist) Social Security Number Date of Birth Barcode DL or ID Number and State Mailing Address Telephone Number: home work mobile PCP Name PCP NPI Medical History (unlimited text) Current Medications Drug Allergies Last Oral Intake Date Last Known Well Date Current Risk Factors: Admits to Drug Use Admits to Alcohol Use Pregnancy Status PMHx Obtained From Barriers to EMS Care: Cultural / Religious Developmentally Impaired Hearing Impaired Language Physically Impaired Psychologically Impaired Sight Impaired Speech Impaired Immunizations List Environmental Allergies List
2 Billing Primary Insurance: Carrier Type Policy Type Carrier Name ID Number Group Number Claims Telephone Number Claims ZIP Code Policyholder Name Policyholder Telephone Policyholder Date of Birth Patient Relation to Policyholder Secondary Insurance: Carrier Type Policy Type Carrier Name ID Number Group Number Claims Telephone Number Claims ZIP Code Policyholder Name Policyholder Telephone Policyholder Date of Birth Patient Relation to Policyholder Next of Kin: Full Name Relationship (picklist) Relationship Explanation Street Address City State ZIP Telephone Number: Home Work Employer: Full Name Street Address City State ZIP Telephone Number:
3 Vitals Assessment Blood Pressure Blood Pressure Measurement Method (picklist) Pulse Rate Pulse Rate Measurement Method (picklist) Pulse Rhythm (picklist) Pulse Quality (picklist) Pulsox SPO2 Pulsox ETCO2 Airway is Patent? Respiratory Rate Respiratory Effort (picklist) Supplemental Oxygen in Use? Supplemental Oxygen Rate Oxygen Delivery Method: NC / NRB / BVM Breathing Treatments in Use: None / Nebulizer / Suction / Vent Tracheal Device in Use (picklist) Lung Sounds Left/Right Upper/Lower (picklists) A/V/P/U (picklist) Pain Level (0-10) (picklist) Pain Level Scale Type Glasgow Coma Score: Eyes (picklist) Verbal (picklist) Motor (picklist) Qualifier (picklist) Body Temperature Body Temperature Method of Measurement (picklist) Blood Glucose Level Notes (unlimited text) Vitals Taken By / When Taken Chief Complaint: Description Duration (picklist) Location (picklist) Body System (picklist) Secondary Complaint: Description Duration (picklist) Location (picklist) Body System (picklist) Mental Status (picklist)
4 Oriented: Person / Place / Time / Event Responsiveness (picklist) Primary Impression (ICD10 codes) (picklist) Secondary Impression (ICD10 codes) (multiple picklists) Acute Symptoms (ICD10 codes) (multiple picklists) Skin Capillary Refill (picklist) PEG/J Tube in Use? Catheter in Use? Complications? Assessed By / When Assessed Drag-and-drop Interactive Exam Findings Chart: Neurological Assessment Neurological Weakness: Left / Left Facial Droop / Right / Right Facial Droop Head Assessment Eyes Assessment Face Assessment Neck Assessment Heart Assessment Back/Spine Assessment Chest Assessment Skin Assessment Lungs Assessment Abdomen Assessment Left Arm Assessment Right Arm Assessment Left Leg Assessment Right Leg Assessment Genital/Urinary Assessment Automatic Popover LAPSS Stroke Screen Procedure Performed Procedure Type (picklist) Authorization (picklist) Number of Attempts / Is Successful? Response (picklist) Complications (multiple picklists) Protocol Applied Physician Name Comments (unlimited text) Performed By / When Performed IV Placed / Checked / Removed Authorization (picklist) Size (picklist) Location (picklist)
5 Number of Attempts / Is Successful? Complications (multiple picklists) Protocol Applied Physician Name Comments (unlimited text) Placed By / When Placed Medication Given Patient's Allergy List is Automatically Dsplayed Warning if Patient is Confirmed Pregnant Automatic Popover Reperfusion Checklist Medication (picklist) Authorization (picklist) Physician's Order and Comments Dosage Dose or Vial ID Route (picklist) Response (picklist) Complications (multiple picklists) Protocol Applied Physician Name Comments (unlimited text) Administered By / When Administered Injury Report Cause (ICD10 codes) and Mechanism (multiple picklists) Cause is Work-Related? Work Industry Patient's Occupation Activity at Injury (picklist) Fall Height in Feet Risk Factors: Alcohol Paraphernalia at Scene Smell of Alcohol on Patient's Breath Drug Paraphernalia at Scene Positive Drug or Alcohol Level Found by Hospital or by Law Enforcement Trauma Factors (picklist) Criteria for Transport to Trauma Center (picklist) Safety Equipment in Use (picklist) OSHA Gear in Use: Eye and Face / Foot / Head / Hearing / Respiratory / Harness / Nets Patient Seat Location (picklist) Airbags Deployed: Front / Side / Other Occurred At Address or Mile Post Occurred At Cross Street or Landmark
6 Notes (unlimited text) Mass Casualty: Triage Classification (picklist) Mass Casualty: Number of Patients Motor Vehicle Incident: Patient Seat Location (picklist) Direction of Impact (picklist) Airbags Deployed (checkboxes) Automated Crash Notification Form: Reporting Company Name Incident ID Incident DateTime Multiple Impacts? Rollover? Callback Telephones: Primary Secondary Incident Location (lat/lon) Vehicle Body Type Vehicle Manfuacturer Vehicle Make Vehicle Year Delta Velocities Primary Secondary High Probability of Injury? Primary Direction of Force Seat Report 1 Location Occupied? Seatbelted? Airbag Deployed? Seat Report 2 Location Occupied? Seatbelted? Airbag Deployed? Airway Intervention Procedures (multiple picklists) Indications (picklist) Response (picklist) Complications (multiple picklists) Length of Intervention Outcome Reason for Failure (picklist) Protocol Applied
7 Physician Name Intubation Device (picklist) Intubation Tube Size (picklist) Intubation Tube Depth Intubation Mark is at Teeth? Ventilator: Mode (picklist) Tidal Volume Respiration Rate PEEP Inspiration Time Exhalation Time Pressure Support Used? Pressure Control Oxygen Mixture Confirmations: Chest Rise Visualization Bulb/Syringe Aspiration Condensation in Tube Direct Tube Revisualization Vocal Chord Visualization Auscultation Colorimetric ETCO2 Digital ETCO2 ET Tube Whistle Waveform ETCO2 Other, Refer to Narrative Notes (unlimited text) Performed By / When Performed ECG Procedure Equipment Type (picklist) Authorization (picklist) Interpretation Method (picklist) Cardiac Rhythm (picklist) Ectopies: Artifact Left BB Block Right BB Block Ischemia - Anterior Ischemia - Inferior Ischemia - Lateral Ischemia - Septal Premature Atrial Complex (PAC) Premature Ventricular Complex (PVC)
8 ST - Elevation ST - Depression Junctional (JET) Idioventricular AV Block - 1st Degree AV Block - 2nd Degree - Type 1 AV Block - 2nd Degree - Type 2 AV Block - 3rd Degree Comments Attach a Strip Image (can photograph a strip using a smartphone/tablet) Performed By / When Performed Cardiac Arrest Report DateTime Occurred Witnessed By (picklist) Etiology (picklist) AED Used Prior to EMS Arrival AED Used By (picklist) CPR Attempted By (picklist) CPR Started DateTime EMS Intervention: First Monitored Rhythm (picklist) CPR Attempted? Reason CPR Not Attempted (picklist) CPR Discontinued DateTime Reason CPR Discontinued (picklist) Return of Circulation (picklist) Outcome (picklist) Neurological outcome (picklist) List of CPR-Related Procedures Performed Notes (unlimited text) Hospital Outcome Emergency Room: Chief Complaint First Systolic BP Diagnosis Codes (ICD-10) Procedure Codes (ICD-10) Cause of Injury (ICD-10) Disposition Admission: DateTime Admitted Diagnosis Codes (ICD-10) Procedure Codes (ICD-10) Days in ICU
9 Followup Days on Ventilator Disposition Discharge: DateTime of Discharge Patient Status External Reports: Type of Report (picklist) Report ID Type of Report (picklist) Report ID Attending Crew Member (picklist) Patient Disposition (picklist) Reason for Transport Reason for Stretcher (picklist) Reason for Stretcher Details Odometer Reading at Start Odometer Reading at End Odometer Readings from the Vehicle's Prior and Next Calls Time Enroute Enroute Driving: Intersections (picklist) Speed (picklist) Siren (picklist) Reason for Delay Enroute (picklist) Time Arrived On-scene First EMS Unit On Scene? Other Services At Scene: Other Service 1 Type Other Service 1 Name and ID Other Service 2 Type Other Service 2 Name and ID First Responder Arrived DateTime Type of Scene (picklist) Number of Patients On Scene Condition of Patient On Scene (picklist) Patient Contacted DateTime Reason for Delay On-scene (picklist) Authorizing Physician Authorizing Physician NPI How Patient was Moved to Ambulance (picklist) Time Transport Began Position of Patient During Transport (picklist) Transport Driving:
10 Intersections (picklist) Speed (picklist) Siren (picklist) Reason for Delay Transporting (picklist) Reason for Choosing Destination (picklist) Type of Destination (picklist) Hospital Designation (picklist) Hospital Inpatient Designation (picklist) Time Arrived at Destination Destination Hospital Capability Destination Inpatient Department Condition of Patient at Destination (picklist) Disposition Instructions Provided (picklist) Time Returned to Service Reason for Delay Returning to Service (picklist) Crew Comments Time Back at Station Personal Protective Equipment Used For Each Crew Member: Eye Protection? Gloves? Helmet? Suit Level A? Suit Level B? Suit Level C? Suit Level D? Mask - N95? Mask - Surgical? Other? P.A.P.R.? Reflective Vest?
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