emsCharts.com Documentation Guide
Contents
1. This should reflect Add Patient When page 1 is complete the outcome of the click this button at the bottom call choices can be of the page to add your customized patient information to the depending on the chart needs of the service Table 1 7 17 2012 Page 7 emsCharts User Guide Adding a Patient Click Search for Existing Patient a When searching for patients be sure to use our program s wild card code the percent sign as shown below It is helpful when you are not sure how to spell a name or how a name may have been originally entered in the system Fig 7 b If no results are found then choose Add New Patient button Fig 8 Patient Records No Patient Selected Page 1 Search for Existing Patient Dispatch VNVN__ FE Last Name Jackson First Name Mar Page 3 Meuro Airway Resp Cardio Secondary Survey Labs Fluids Page T Meds lis PTA Page amp Activity Log Page 9 Misc Forms Entire Chart Print Preview Special Report Chart Toolbox Fig 7 No records found Add new Patient Fig 8 c Enter the new patient s information in this window and save Fig 9 Patient Information PTID 0 our Last Smith First John Middle Unknown SSN Address E Unknown Address Sex E International Blood Type hi city St 7ip hi 4 Resident Weight Kg County Citizen of United States Barriers to Care Not Rec2. Impedance Threshold Device Respirator Operation CPAP BiPAP Cardiac CPR CPR AED Mechanical CPR Cardiac Monitor Vagal 12 Lead EKG Transmitted Defibrillation Chilled Saline Administration Patient Cooing Post Resuscitation Medical Consult Contacting Command Child Birth OB All procedures pertaining to Childbirth OB Rescue Operation procedures Extrication types Wound Care All procedures regarding care of wounds bleeding Hospital Notify Hospital Notification 7 17 2012 Page 23 emsCharts User Guide Page 9 Miscellaneous Forms 1 This is the wrap up area of the chart a There may be a variety of forms or options to complete here in addition to locking or advancing the chart to the next QA level when it is finished Attached Files Attached Files You are able to scan Optional pehes t d Reason for Transport Optional Number of Attached Files 0 page 2 documents and re _ PT CC HPI ____ Activity Audit Optional Sign Chart View electronically attach F Utilization Review optional Pt Followup Log Number of Signatures 1 Print Chart Chat Forms Chart amp Foms ep caso them to the chart Page 5 Secondary Survey Page 6 Labs Fluids Current Initial Entry 50 Remember to sign the chart rent Til Ey C po Las if required More than 1 addendums signature may b
3. To look up medical history page medications or allergies type the first couple of letters here or choose the first letter and pick from a list Also if what you are looking for is not in the look up list then type it in the free text area click add and when finished click done to save all entries made amp Internet Fig 14 7 17 2012 Page 11 emsCharts User Guide Page 2 PT CC HPI 1 Impression Diagnosis a Choose the best description of the patient s problem from the drop down menus in each of these areas b Condition at Destination Impression Diagnosis Scene Description Symptoms Impression Condition At Dest Other EMS Chief Complaint Other Agencies Duration of Complaint Disaster CMS Condition Code Cond Code Modifier Secondary Complaint Custom Base Fee Patient Belongings Duration of Complaint bd History of Present Illness Entire Chart Patient Movement Print Preview j c These are spell Moved to Vehicle Via Special Report Chart Toolbox Position in Vehicle check buttons for Moved From Vehicle Via aad each fr ee text box From e Joos ort Rec E Lab Work Reason for Encounter Photos Drugs Alcohol X Rays Factors Affecting Care Dispatch Factors Response Factors Scene Factors Tran
4. time you can select or deselect that time b Some times will be required according to Outcome chosen Page 1 Details Fields at the top of Some fields at the Crew Members Crew members entered in page 1 top of page 1 are EMS charts will be found in customizable you the menu You can manually may or may not see enter other personnel from them Use whatever assisting services in the IDs your service other box requires Basesite and unit Customizable Referring Referring is who called according to the most often you will select service other and enter the address of the residence location but for situations like an ALS assist or transfer you can select EMS or hospital Response Customizable based How you responded to the on your local scene dispatch system Type of Service Scene and Receiving Most often you will select unscheduled are hospital however if you the defaults for transfer care to another EMS these fields Other unit you could select EMS choices are or other for a transfer available from the drop down The mosi common however for transfers interfacility or other can be selected Scheduled or unscheduled can also be selected depending on a 911 call or scheduled transfer Category Category should be Comment This is the first of many the condition most opportunities to write closely related to the comments and build a patient s condition narrative
5. Transport INTAKE Before During CRYS COLL Entire Chart OTHER OTHER Special Report Chart Toolbox Next Page ao Fig 25 3 Priors below a For those IVs and medications that were given to the patient PRIOR to your arrival b Able to document as much as you re told about these interventions to have the information on the chart c NOT for medications and or IVs YOU did for the patient those go on Page 8 Activity Log a IVs Initiated Prior to Assessment wae IV Gauge Site Solution Rate ml hr Performed By Outcome lock lock Other Healthcare Provider Unchanged F F Medications Infusions Prior to Assessment Concentration Dose Rate IV Other Route Performed By Outcome Drip d voi Misc Forms Entire Chart Print Preview Special Report Chart Toolbox Fig 26 7 17 2012 Page 20 emsCharts User Guide Page 8 Activity Log 4 What goes on Page 8 a Everything about your patient encounter after their initial primary and secondary survey chart pages 2 7 should be documented here b You will document ALL medications interventions and treatments you performed on your patient here c You can add comments individually or combine your comment with the documentation of other interventions 5 Each comment instance allows up to 4000 characters to continue your narrative if necessary 6 Times a Times are imported from the Dispatch page to ass
6. EMSCHARTS COM emsCharts New User Handbook emsCharts User Guide emsCharts User Guide EMSCHARTS COM emsCharts New User Manual emsCharts 600 Mifflin Road Suite 102 Pittsburgh PA 15207 Phone 866 647 8282 Fax 412 461 3270 v 1 0 0 7 17 2012 Content Provided by Deborah McCoy Freeman Linda Coene emsCharts User Guide emsCharts User Guide 1 Introduction a This document is intended to serve as a guide to entering a patient record into emsCharts i The screen shots you see here may look different to the way your chart is or will be set up Administrators may turn specific fields of or on and also control many lists shown 2 Basic emsCharts com Navigation Information a Use of the Tab Key i The most common way of moving around a web page is with the mouse However there is an alternate method in the Tab key This key located in the upper left hand section of your keyboard lets you move from one page element to the next li Also if you go past the element you were trying to reach you can hold the Shift key and press Tab to move backwards through the page elements b Search Boxes i Searches are used to look up hospital names public safety agencies EMS Fire Police Communication Centers users services and command facilities The reason for these searches is so that the database can store the ID number associated with an object rather than the name 1 This will eliminate incorrect spelling
7. e I See below Current Login Type Service Coene Demo EMS home sodell 11 14 11 Configuration At a Glance Service Login Patient Records Incomplete Charts 0 Change Login Coene Demo ENS Charts Flagged for QA 0 Base Moris County Unanswered QA Flags 0 New Special Reports 326 special Reports Forums Unit 201 Shift Sita Continuing Ed Reports Calendar 11 14 2011 12 12 2011 Human Resources No Events Found At A Glance This section Calendar System Messages TTT Li ae eae will display the number of Suppor Pricing Announcement No price increase in 2012 for emsCharts customers Read more your incomplete charts ee emsCharts Mobile v3 Release Schedule Announced click here for details charts flagged for QA and Securty Sena eee messages from other We are having a sdldfvlkk optional features of Welcome to emsCharts Please go to configuration user to enter your demographics and certification information emsCharts Fig 3 f System Messages i If messages appear here they will always be in the following order 1 emCharts Status anything we need to communicate to our users will be here 2 State region If your state or region uses emsCharts to communicate with its users those messages will come next 3 Command Facility emsCharts will be next 4 Service Announcements Messages from you
8. e medical calls 4000 characters here also 6 Patient Belongings and Patient Movement a Free text box 2000 characters to describe patients belongings as well as a section below to choose how your patient was moved though out the call 7 Forms and Factors a The forms section is optional depending on the types of calls your service runs b The factors affecting care section includes drop down menus with the most common factors affecting each part of the call 7 17 2012 Page 13 emsCharts User Guide o Patient Records Page 1 Dispatch Page 2 PT CC HF Page 5 Secondary Survey Labs Fluids Page T Meds I s PTA Page 3 Activity Log Misc Forms Entire Chart Print Preview Special Report Chart Toolbox Open Support Fig 17 Page 3 Neuro and Airway Assessment i 1 Neuro Assessment a D C d Use the drop down menus picklists and comment boxes for the patient s neuro assessment If a Stroke Scale was used indicate what type and your result from that drop down menu Pupillary Motor and Sensory assessments Upper right hand corner to document findings and brief comments for all 2 Immobilization a D C If you answered yes to Was Pt Immobilized the immobilization field will appear to document how who immobilized the patient prior to your arrival If no these fields do not show You can choose PTA to a
9. e required Current Numbel f Addendums 0 Chart Toolbox contains some Fig 31 utilities that may be useful such as deleting a chart while it is still in the authoring stage before it s locked Once the chart is locked you can use the addendum feature to make your late entry This will auto date time stamp and adds your name to a 4000 character max notation box for each addendum instance Once the chart is finished signed and considered to be complete it will be time to Lock the chart for QA In this area you can see at what QA level the chart is and what level it will go to once it 1s locked in this case it will go to QA Level 1 QA Supervisor for review The locking procedure checks the chart for any data validations and then packages it for export The items on the left side of Page 9 are optional and may or may not be used by your service They are add in items that they will train you on if they decide to use these functions of emsCharts Thank you for using emsCharts 7 17 2012 Page 24
10. easy installation gt 100 elimination of resources needed for Once you have logged In Testimonials system support you will be asked to note sales change your password to a secure password National Coverage See More gt Copyright 2012 emsCharts 600 Mifflin Road Suite 102 Pittsburgh PA 15207 Phone 1 866 647 8282 Fax 412 461 3270 sales emsCharts com er in Fig 2 3 emsCharts Home Page a Upon log in you will see the screen below This page will be revealed once you complete the security setting for first time log ins b Red Service Login Box i Use this box to change your login Service or Type li Your current login type and service will always be visible in the upper right hand corner as you navigate through emsCharts iii If you work for multiple agencies using emsCharts be sure that you are logged into the correct service to begin your chart 7 17 2012 Page 2 emsCharts User Guide iv Base and Unit should be entered for automatic entry when a chart is Started c Logout Button upper right hand corner i This is a kill switch and will immediately log you off the system d Home Button upper left hand corner under our logo I Clicking on home will bring you back to this page and the home page menu options in the column on the left li These home page menu options allow you to access a variety of functions for emsCharts Your features may differ as many are customizable e Ata Glanc
11. ece Derene Namef OQ import Data Doe John M Please Select A from the Unit Emergency Department Open Support Rec RN drop down Mode Lignts Srens Dest Basis E menu Dest GPS N E Comment u uents Odometer readin gs can be ick button below to add patient calculated to 0 1 mile Add Patient gt gt Fig 6 When finished with this page click add patient to continue Referring From whom where did you receive this patient a EMS if you are called to assume care of the patient from another ambulance or Quick Response Unit b Hosp in the case of a transfer c Other for most other 911 calls d This is commonly called the Pick up location Receiving To whom did you transfer care of your patient a Hosp is the default here so just choose the appropriate facility from the drop down menu b If you transfer care to another EMS service you should select EMS and then choose the appropriate service from the drop down c If you transferred care to anyone other than a hospital or EMS then choose Other and you may be able to choose from the looking glass any common 7 17 2012 Page 6 emsCharts User Guide address entered into your system for a common location in your response area You may also type a complete address if not provided d This is commonly called the Taken to location Times a This area allows you to enter times By clicking the box to the left of each
12. flagged charts would be listed above Fig 5 emsCharts User Guide 7 17 2012 Page 5 emsCharts User Guide Page 1 Dispatch Page Notice a patient record is broken up into 9 pages Currently this is page 1 A record ID may be required by your service They may change the label of this field gt Patient Records Test Field Value Page Select the Create TEST chart Dispatoh ___ ___ 7 IA Onset f 06 21 12 12 19 sn category pfetmntmeceet out 20 General Dsp Notified i7 p Notified ff 06 21 12 12 19 ones from the Basesita Coene Base Type C Hosp C EMS _ amp Other Neuro Airway __ dro Unit 132 mi BLS EA Other Type x P ift Daytont Location IO Page 5 down Response LightS sad Si Fi zip Secondary Survey n l Secondary Survey Svc Scene ched Cconyl sd Labs Fluids menu egory 7 Page 7 Dispatched As Not Recorded x MCD Semona El Meds I s PTA Outcome Treated Transported by EMS 7 Requester Page 8 j tivity Log Mass Casualty Not Recorded Ref GPS Page 9 Dispatch Loc IN E Mise Forms Select the phe GPS 40 673197 0 142071 e Mode Lights Sirens EI RFT Entire Chart Crew Members mure appropriate CoepptefsChants Linda Attendant Special Report PWallace Dane EMT Type Hosp EMS Other outcome si
13. ist you in accurately documenting your entries b Each entry on the Activity Log MUST be accompanied by a time We won t let you forget the time as a reminder will appear when the time field is blank Patient Records At Ref 12 33 Lv Ref 12 33 At Rec 12 33 Dispatch Method MAP a02 RESP Resp Effort 02 09 12 SpCO Custom Vital 2 Label e Value Custom Vital 1 Label e Value Comments Fees Click these a ETE buttons to auto ma E E fill previous vitals then Assessed By hd change what is different or document no change in patient condition Misc Forms Add Action SAVE Add Line Fig 27 Note fields for blood glucose GCS pain scale and customizable vitals labs Add Action is described in detail on the next page Save each item as you wish to add more detail lines 7 17 2012 Page 21 emsCharts User Guide 7 Add Action a Specific actions medications and interventions are documented using the Add Action drop down menu as shown below b Oxygen administration and immobilization are actions that can be documented by entering a time and documenting anything else you wish for that time c At the bottom of the log box click the Add Action drop down menu to choose which action you are logging d Once you click Save Add Line a ne
14. o the web page i Some boxes enforce a maximum length to the amount of data that can be entered into them if you are typing and no more text is appearing in the box chances are that you have exceeded the amount of data the box can hold d Type www emscharts com into your web browser to go to our home page e Enter your username and password Request Information Products Event Technology Company Training emsCharts password E Remember me Whats this our password Nov 09 No price increase in 20 emsCharts Customers Jan 20 See us at Fire Rescue EAS Charts Web based 2012 Electronic Patient Data Feb 07 See us at NCAEMS Winter Conference 2012 Feb 15 See us at Tennessee Ambulance Association 2012 See More News gt gt n Type in your username emsCharts and management solutions emsCharts s primary software is delivered and asswo rd If ou les air medical and ground as an online service and affords our p y ccess to web based data emsCharts SyncPen customers the benefits listed below h ave never logg ed in ship No annual software maintenance fees No need to purchase or manage servers before use the username a total solution at a flat emsCharts mobile middleware or databases are and software licenses No significant infrastructure start up and temporary password Free sofware upgrades that you were assigned cauirs and disseminate ng a number of interfacing Rapid implementation amp
15. orded Phone DOB Age Race DL State DL Number DNR Fig 9 7 17 2012 Page 8 emsCharts User Guide d Note that the patient s name is Marianne Jackson and how the was used in the search to retrieve all possible entries with last names beginning with Jackson whose first name begins with Mar This provides a more comprehensive search and a list from which to choose the correct patient Il Once you have verified her SSN and or DOB you may choose the corresponding patient by clicking on the desired name in blue ll This will result in the patient information past medical history current medications and allergies from their last record to be brought forth for you to use in this new patient care record Selection Dialog Box Windows Internet Explorer Last Name Jackson Jackson Marianne 012 34 5678 10 13 1949 Jackson 000 00 0000 10 15 1927 Jackson 11 15 1931 Jackson 789 78 9778 12 15 1922 Jackson 999 99 9999 05 17 1922 Jackson Jackson 195 45 1478 10 16 1941 Add new Patient Fig 10 7 17 2012 Page 9 emsCharts User Guide The Patient Page This page is divided into three sections for ease of display 1 Demographics i Not all fields may be turned on for your service li Not all fields must be completed iii If name or address is not available choose Unknown iv Date of Birth When you tab away from this field it auto fills the age for yo
16. p Cardio Page 6 Labs Fluids Page T Meds IVs PTA Page amp Activity Log Page 9 Misc Forms Entire Chart Print Preview Special Report Fig 20 Your service has chosen one of two available options for the Secondary Survey on page 5 Option 1 Picklist drop down and text box assessment 1 Clicking the chart icon will display common assessment findings under each category 2 There are free text fields to document your assessment of the extremities in the example below Page 5 Secondary Survey Option 1 Findings Trachea Not Appreciated Assessment Assessment eure Left Upper f Spine IE Right upper B i Thoracic f3 o LettLower S mar SP Assessment i Norma Right Lower Findings Additional Information Figs Restraints hin O assessment 7 17 2012 emsCharts User Guide Option 2 Anatomical Exam 1 Run your cursor over each anatomical area and it will turn it GREEN Then click on it and an assessment box will open to the right with picklists and or free text fields for injuries or assessment values Once an area has been assessed it will remain RED 2 The RED text in the External Skin assessment box means that there is data already documented there The Unspecified box contains more assessment values Page 5 Secondary Survey Option 2 _ E Amputation E Bleeding Controlled i Bleeding Uncontrolled El Bu
17. r service 7 17 2012 Page 3 emsCharts User Guide 5 Writing a Patient Care Report a Access the Patient Record menu option from the home page Ogin Type Service To start a new chart choose Coene Demo EMS Patient Records m home 11 14 11 Configuration At a Glance Service Login Patient Records Incomplete Charts 0 Change Login Coene Demo EMS s Special Repons Chats Flagged for QA 0 Base lorisCouny v a Forums Unanswered QA Flags 0 Continuing Ed New Special Reports 326 a Reports Calendar 11 14 2011 12 12 2011 Human Resources No Events Found Calendar System Messages O Dell Sue Links emsCharts com Status Coene emsCharts Linda Suppor 11 09 11 Pricing Announcement No price increase in 2012 for emsCharts customers Read more Unit 201 Shift Shit 201 Crew Wallace Darlene Trainin ne 10 20 11 emsCharts Mobile v3 Release Schedule Announced click here for details Security Settings ay 05 04 10 We are having a sdldfvikk 10 16 06 Welcome to emsCharts Please go to configuration user to enter your demographics and certification information Fig 4 b Creating a Blank Chart emsChars cam LE home 11 14 11 Create Chart Create blank chart Patient Records Search Incomplete Chars Open Suppor Charts Flagged For Quality Assurance You have no flagged charts Click this box to start a new chart Your incomplete charts and or QA
18. r when the patient is ALREADY on a ventilator upon your arrival 2 Cardiovascular Assessment a Most of these fields are self explanatory b Note the Pacemaker button and associated box on the bottom right will be available when the level of care of the chart is ALS c This is used for when the patient is ALREADY being paced upon your arrival RESPIRATORY _ Patient Records Effort Labored Breath Sounds L Rales R Raes Page 1 auscultated 1 3 way up bilaterally ee ee Patient O 4 min Via NC Performed By Law Enforcement Outcome Improved F Page 2 ments Increased work of breathing but alert and cooperative PT OC HPI Page 3 CARDIOVASCULAR eae eee Page 4 Sa Carotid Strong Page 5 Radial Strong Normal Secondany Survey Page 6 Labs Fluids Page T Meds IVs PTA Page amp OL ES Page 9 Misc Forms Femoral Strong Dorsalis Normal Temp E ot Svailable Wo NotAppreciated Zap Refill Less than 2 Seconds Edema NotAppreciated H dbe kR Comments Entire Chart Print Previews Special Report age gt gt Chart Toolbox Import Data Open Support Ventilator Mode Rate FiQ2 Fig 19 7 17 2012 Page 16 emsCharts User Guide Page 5 Secondary Survey Patient Records Page 1 Dispatch Page 2 PT CC HPI Page 3 Neuro Airway Page 4 Res
19. rn E Crush E Dislocation Fracture E Gunshot El Laceration E Not Applicable E Not Available El Not Known E Pain w o Swelling Bruising E Puncture Stab E Soft Tissue Swelling Bruising L Primary Injury Additional Exam Information Fig 22 3 The Obstetrics assessment box is available if you chose Female on the patient page Obstetrics Is patient pregnant Yes v Gravida Para Gestation vks EDC LMP date Initial FHR min Contractions Freq 1 min Dur Membrane Intact v Rupture Time Dilation Effacement Presenting Part Bloody Show Comments co Fig 23 7 17 2012 Page 18 emsCharts User Guide 7 17 2012 4 The Burns assessment box has been enhanced to allow two different methods of calculating burns Total Body Surface Area or Rule of 9 s Burn Assessment fle of 9 s i Anterior Pelvis GU Left Upper Arm Right Upper Arm Left Upper Leg Right Upper Leg Genitalia Fig 24 No Annotations found TESA bo ist Degree bp 2nd Degree po 3rd Degree po Burn Type No burs appreciated Singed Nasal Hair N Carbon in mouth Poor ventilation CO Level Page 19 emsCharts User Guide Pages 6 Labs Intake and Output amp 7 Priors 1 Labs 1 amp O a Mostly used for critical care transport or long distance transport b Optional for most services NOT providing critical care Intake Output Before amp During
20. s Use this field to place next of kin or guarantors for insurance if other than patient ii Primary Method of Payment choose from the drop down Enter Billing Information below RCE CEE EEE Billing Information NPP Form Given Consent Form Signed Medical Necessity Signed Primary Method of Payment v History No v No v X Dares eee Relationships Guarantors Billing Information Misc Forms Steven Jackson Highmark gord gold Entire Chart Fig 12 Billing information such as insurances can be added or edited here 7 17 2012 Page 10 emsCharts User Guide 3 Current PMHX Medications and Allergies I a Clicking the chart icons will open a box below to allow you to look up Current PMHX Current Medications and Current Allergies li The X icon will delete entries after highlighting them iii To document none choose the S icon iv If you chose the wrong patient in the search window and need to replace it or add a new patient instead click Replace Patient Current PMHX Current Medications 4 at Current Allergies Diabetes Type 1 Insulin Pump Hypertension Lisinopril Obtained From Patient Emergency Info Form No Replace Patient Fig 13 M Request To Add J K L M W xXx Y 7 Once done with patient information billing information and past medical history click Next to progress to Page 2 and save your entries on this
21. s poor data entry and provide the ability to search efficiently For example when a user changes their last name only the displayed name will change The number behind the name will remain the same thus allowing searches across the time span when the name changed li Fields in which searches are required are indicated by having the same color as the background immediately surrounding them The text boxes will be read only and will have an icon to their right Clicking on this icon will display the search box 3 Search for Users Name Pitt County Memorial Hospital A Q Search for Hospitals EMS and other Sample of Searchable Text Box Search boxes are divided into two sections The top portion Figure 11 and Figure 12 lists the possible criteria to search upon The search is case insensitive does not distinguish between upper and lower case letter however spaces do count There are also two special characters you can use while searching These are called the wildcards and are listed in the tables below oe ee ee eee Univ Starting with Univ Percent Sign None or more characters S Vvin Starting with the letter S and containing _the letters VIN ob Second and third letters are ob Rob Bob Robert as well as Jobe etc __ Underscore Exactly one character Fig 1 7 17 2012 Page 1 emsCharts User Guide c Text Boxes i Text boxes allow you to type information directly int
22. sport Factors SATAA Turn Around Factors E Set All Factors to None lt lt Back Next Page gt gt Fig 15 2 Complaints a Enter Chief Complaint and Secondary Complaint an optional field using no more than 50 characters for each field Notice you can also choose duration from the box below 3 History of Present Illness a This free text box allows up to 4000 characters equivalent to 2 type written pages for your description of the patient s history of present illness 4 Cardiac Arrest Button a Information about the cardiac arrest that is in progress upon your arrival goes here Other buttons may appear depending on the type of call in progress Cardiac Arrest Button Cardiac Arrest Registry Witnessed ff 08 31 05 13 32 Who Witnessed N A Cardiac Etiology This is a box to document the care that was given regarding the cardiac arrest that was in tt ree progress PRIOR to your arrival ALs initiated 7 Remember we use page 8 to chart our actions medications and treatments for the patient Ventilation Returned f 08 34 05 13 32 Dest Rhythm f 7 17 2012 Page 12 emsCharts User Guide 5 Scene Description a Use this box to describe the crash scenes You should describe the damage to all the vehicles involved and any hazards on the scene You can also document the condition of the house on routin
23. u v Ifthe calculated age is less than 19 some pediatric assessment fields will be available vi Choose Female as appropriate to open an OB Gyne assessment box on Page 5 Patient Records Page 1 Dispatch Patient Information PTID 10425314 our WV ID SST Stee SESS Last Jackson First Marianne Middle FJUnknown SSN 012 34 5678 a Sass DAC P Address 121 Main Street FT Unknown Address Senci Fomio v ag qu e ET International Blood Type ial Neuro Airway City St Zip Pittsburgh PA 15201 Lookup Q Resident Yes Weight kg v County JAlegheny Citizen of United States x Barriers to Care Not Recorded v gt 0 Phone 412 412 4123 DOB 10 13 1949 ol Age amp Yr Race White non Hispanic kd ee DL State DL Number DNR immunization _Emniovec Phwaician Labs Fluids A These fields may be available as well Note that if the text on the box is red there is information already listed there and can be reviewed and or edited The patient demographics billing information PMHX Meds and Allergies from the previous chart is imported into this chart to be validated Fig 11 2 Billing Information i NPP Form Given Choose from the drop down menu to document that the HIPPA form was signed and or check the history link to verify when the patient last signed this form and what version it was li Relationships Guarantor
24. uto fill Prior to Arrival for collar CID and LBB N A will auto fill in the KED and Mast fields You can then use the dropdown menu to choose who performed the immobilization and what they felt the outcome of that intervention was 3 Broselow Color a Ifa pediatric age is calculated on the patient page this field will present itself to you to choose the color on the length based tape that you used for this patient 4 Airway a Airway assessment is done here You can comment on how the airway was being managed and by whom prior to your arrival b This is NOT for any airway interventions your crew may have done That is done on the activity log Page 8 7 17 2012 Page 14 emsCharts User Guide Level of Consciousness Alert ental BJ Comments Stroke Scale Patient chemically paralyzed No Loss of Consciousness No Was Pt Immobilized Immobilization CID KED Performed By Broselow Color Airway Status Patent Comments Performed By Fig 18 7 17 2012 Page 15 emsCharts User Guide Page 4 Respiratory and Cardiovascular Assessment 1 Respiratory Assessment a Choose from drop down menus and comment fields to document the patient s respiratory assessment including any oxygen that might have been in place prior to your arrival b Note the Ventilator Settings button and associated box on the bottom left will be available when the level of care of the chart is ALS c This is used fo
25. w box will appear This box is customized according to the action you chose and allows for quick documentation v Assessed By Entire Chart Print Preview Special Report Notes Chart Toolbox Place the mouse over the vitals and click to edit delete Import Data Open Support e Selecting Airway Other and clicking Save Add Line will bring up the Airway Log box below left f Selecting Immobilization and clicking Save Add Line will bring up this Immobilization Log box below right 08 31 05 Airway Loc __ Crew ID __ vw Yes M Oxygen v Ipm Complication 08 31 05 Im v F Long Board C Pediatric Immob Device C Cervical Immobilization Device Traction Splint O Cervical Collar Fj Splint O keD C MAST Applied C Short Board C MAST Inflated C Manual C Spine Stabilzation hs w Comments Authorization wv Fig 29 Submit Information Fig 30 7 17 2012 Page 22 emsCharts User Guide 8 For each Add Action box there are specific procedures Please refer to the table below Documentation of Specific Procedures on Page 8 Activity Loa Add Action Menu Procedures that can be entered Options Medication Administration Intubation Any type of Intubation Advanced Airway Airway Other Abdominal Thrusts Foreign Body Removal Bag Valve Mask Oxygen Suction Oral Airway Nasal Airway
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