Run Information
Dispatch & Chief Complaint
Onset Duration
Chief Complaint
Quick:
Neuro / LOC
Physical Exam Findings
Trauma Survey โ DCAP-BTLS
DCAP-BTLS
Deformity ยท Contusions ยท Abrasions ยท Punctures ยท Burns ยท Tenderness ยท Lacerations ยท Swelling
Respiratory Assessment
Work of Breathing
Effort / pattern observed
Lung Sounds
Bilateral auscultation
Speech Quality
Sentence completion ability
Skin Assessment
Skin
Color ยท Temperature ยท Condition
Head, Eyes, Ears, Nose, Throat
HEENT
Head ยท Eyes ยท Ears ยท Nose ยท Throat
PERRLA
Pupils equal, round, reactive to light
Battle Signs / Raccoon Eyes / CSF
Head trauma indicators
Neck / C-Spine
Deformity or pain to palpation
Abdomen
Abdomen
Palpation assessment
RDGTP ร 4 Quadrants
Rebound ยท Distension ยท Guarding ยท Tenderness ยท Pulsation
Extremities
Distal PMS ร 4 Extremities
Pulse ยท Motor function ยท Sensation
Pertinent Negatives
Green = denied/absent ยท Red = present
Vital Signs
GI / IntakeโOutput
GI sentence only appears in narrative if any field is used.
Stroke Assessment
DNR / Advanced Directives
DNR line only appears in narrative if a status is selected.
Medical History & Treatment
Allergies
Medication Allergies
Food Allergies
Other Allergies
Treatment ืืืคืื
Transport ืืืคื ืคืื ืื
Live Narrative Output
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โก๏ธ ื ืจืืื ืืขืืจืืช
English Review
Cardiac Monitor & 12-Lead
12-Lead ECG
Interventions
IV / IO Access & Fluids
Medications Administered
Advanced Airway
Medical Direction