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Identifying information Observ
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Arrival time documented Clock time
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{clock_time}
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Transport mode EMS Sys
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Ambulance transport unit EMS Sys
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Ambulance transport agency EMS Sys
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Referral Source Class
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Chief complaint+Reason for visit
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Initial visit for chief complaint
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Acuity assess 1st enctr
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Responsiveness assessment 1st enctr
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GCS eye 1st enctr
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GCS verbal 1st enctr
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GCS motor 1st enctr
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BP sys 1st enctr
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mm[Hg]
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BP dias 1st enctr
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mm[Hg]
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Heart rate 1st enctr
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{beats}/min
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Resp rate 1st enctr
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{breaths}/min
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Bdy temp 1st enctr
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Pregnancy status Reported
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E
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Illness or injury onset date and time
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Injury incident description
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Injury cause
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Injury location
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Injury associated activity
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Injury intent
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Safety equipment used
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Source of info
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Chief complaint Reported
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Hx of Pres illness
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Problem list Reported
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Hx of Past illness
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Social Hx
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Marital status+living arrang
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Current employment Reported
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Hx of Occupation
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Hx of Alcohol use
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Alcoholic drinks/drinking D Reported
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/d
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Alcohol binge episodes/M Reported
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{#}/mo
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Hx of Tobacco use
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Cigs smoked (pack/day) nRate Reported
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{#}/d
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Cigs smoked (pack/year) nRate Reported
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{#}/a
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Hx of Other nonmedical drug use
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Highest level of educ
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Hx of Sexual behavior
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Hx of Travel
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Family member diseases Hx
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Review of systems
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Hx of Eyes disorders
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Hx of ENSMT disorders
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Hx of CVS disorders
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Hx of Respiratory disorders
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Hx of GI disorders
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Hx of GU disorders
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Hx of Reproductive disorders
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Hx of Urinary disorders
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Hx of Musculoskeletal disorders
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Hx of Integumentary disorders
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Hx of Skin disorders
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Hx of Brsts disorders
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Hx of Neurologic disorders
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Hx of Psychiatric disorders
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Hx of Endocrine disorders
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Hx of Hematologic disorders
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Hx of Allergy+Immunologic disorders
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Phys find
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Phys find General status
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Heart rate Periph a Palpation
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{beats}/min
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Resp rate
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Body temperature
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Cel
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Weight
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GCS total
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{score}
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GCS eye
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GCS verbal
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GCS motor
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Phys find Head
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Phys find Neck
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Phys find Chest
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Phys find Chest wall
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Phys find Brsts
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Phys find Axilla
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Phys find Hrt
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Phys find Thorax+Lungs
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Phys find Abd
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Phys find Groin
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Phys find Pelvis
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Phys find Genitalia
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Phys find Male genitalia
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Phys find Female genitalia
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Phys find Buttocks
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Phys find Rectum
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Phys find Back
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Phys find Hand
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Phys find Wrist
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Phys find Forearm
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Phys find Elbow
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Phys find Upper arm
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Phys find Should
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Phys find LE
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Phys find Ft
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Phys find Ankle
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Phys find Calf
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Phys find Knee
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Phys find Thigh
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Phys find Hip
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Physical exam by systems
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Phys find Eye
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Phys find ENMT
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Phys find Ear
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Phys find Nose
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Phys find CVS
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Phys find Vesl
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Phys find GU Tract
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Phys find Musculoskeletal
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Phys find Skin
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Phys find Neurologic
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Mental status
?
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Phys find sensation
E
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Phys find Strength
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Phys find Balance+Coordination
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Phys find Deep tendon reflexes
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Psychiatric findings
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Phys find Hem+Lymph+Immun
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Surgery procedure
E
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ED procedure result type
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ED procedure result observation Imp
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Medication administered
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ED dc dispo
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Medication.discharge:Find:Pt:^Patient:Nar:
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Payment Dx
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