Ems Medical Record Form PDF Details

Emergency Medical Services (EMS) teams across the Commonwealth of Virginia rely on the EMS Medical Record - Short Form to accurately document critical patient information during the fast-paced and often chaotic emergency response situations. This comprehensive form captures a wide range of data points essential for the subsequent care and treatment of the patient. It includes identifiers like agency and incident numbers, patient demographics, chief and secondary complaints, detailed symptom chronology, and vital patient history. Additionally, it outlines the response timeline—from the moment the unit is dispatched to the patient's arrival at the destination. The form further delves into a patient's medical history, allergies, medications, and provides a structured section for recording assessment and vital signs multiple times through the course of care. Treatment narratives, medication administration, and advanced procedures such as airway management and intravenous therapies are meticulously logged. Signatures from the attending EMS personnel validate the form, ensuring a traceable and accountable record. This short form, by design, supports not just immediate patient care needs but also serves as an indispensable link in the continuum of care, providing emergency room teams and subsequent caregivers a detailed snapshot of the patient's pre-hospital condition and interventions. While it's clearly stated that this isn't intended to replace a full medical record, its significance in emergent care cannot be overstated, making it a cornerstone document within the EMS documentation suite.

QuestionAnswer
Form NameEms Medical Record Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesVirginia, ECG, irreg, pcr ems

Form Preview Example

Commonwealth of Virginia

EMS Medical Record - Short Form

 

Agency:

Agency #:

 

Unit #:

 

Date: D D / D D / Y Y

 

 

 

 

 

 

 

 

Location:

 

ZIP

Incident #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender:

Name:

 

 

 

 

 

 

 

 

 

 

Age:

 

 

Male Female

Address:

 

 

 

 

 

 

 

 

Apt/Rm

Telephone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

State:

 

ZIP:

 

 

 

 

 

 

 

Next of Kin Name:

 

 

 

 

 

 

Rel.

 

Tel.#:

 

 

 

 

 

 

 

SSN/DL #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DL State

 

 

 

M

M

 

D

D

 

Y

Y

Y

Y

 

 

Chief Complaint and Duration

 

Secondary Complaint and Duration

 

 

 

Symptoms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Times (24hr Format)

PSAP Time

Unit Disp.

Enroute

Arrive Scene

Arrive Patient

Leave Scene

Arrive Dest.

Patient and Response Information

Patient History

Assessment/Vital Signs

Treatment

Narrative

Signatures

Past Medical Surgical History

None

COPD

GU/GI

Hypotension

Seizures

Tuberculosis

Allergies:

Asthma

Develop Delayed

High Cholesterol

Neuro

Stroke/CVA

Other:

 

Cancer:_________

Diabetes

HIV/AIDS

Psych Disorder

Substance Abuse

 

 

Cardiac:_________

Endocrine

Hypertension

Renal Failure

TIA

 

 

Medications:

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

LOC

B/P

Pulse

Resp.

SpO2

Pain

ECG

 

 

Time

LOC

B/P

 

Pulse

 

Resp.

SpO2

 

Pain

ECG

 

A

/

 

 

 

 

 

 

 

 

 

 

 

 

A

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

RA

 

 

 

 

 

 

V

 

 

 

 

 

 

 

RA

 

 

 

 

 

Gluc.

P

Palp

Regular

Regular

1-6 L

CO2

Defib Joules

 

Gluc.

P

Palp

Regular

Regular

1-6 L

 

CO2

Defib Joules

 

U

Unable

Reg-Irreg

Reg-Irreg

7-9 L

 

 

 

 

 

 

U

Unable

Reg.-Irreg.

Reg.-Irreg.

7-9 L

 

 

 

 

 

 

n/a

N/O

Irreg-Irreg

Irreg.-Irreg.

10-25 L

 

 

 

 

 

 

n/a

N/O

Irreg.-Irreg.

Irreg.-Irreg.

10-25 L

 

 

 

 

Time

LOC

B/P

Pulse

Resp.

SpO2

Pain

ECG

 

 

Time

LOC

B/P

 

Pulse

 

Resp.

SpO2

 

Pain

ECG

 

A

/

 

 

 

 

 

 

 

 

 

 

 

 

A

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

RA

 

 

 

 

 

 

V

 

 

 

 

 

 

 

RA

 

 

 

 

 

Gluc.

P

Palp

Regular

Regular

1-6 L

CO2

Defib Joules

 

Gluc.

P

Palp

Regular

Regular

1-6 L

 

CO2

Defib Joules

 

U

Unable

Reg-Irreg

Reg-Irreg

7-9 L

 

 

 

 

 

 

U

Unable

Reg.-Irreg.

Reg.-Irreg.

7-9 L

 

 

 

 

 

 

n/a

N/O

Irreg-Irreg

Irreg.-Irreg.

10-25 L

 

 

 

 

 

 

n/a

N/O

Irreg.-Irreg.

Irreg.-Irreg.

10-25 L

 

 

 

 

 

 

 

 

 

Medication Administration

 

 

 

 

 

 

 

 

 

 

Airway/Intravenous Procedures

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

Medication

Dose Route

Resp. Crew #

Time

Medication

Dose

Route

Resp

Crew #

Time Size Type Loc. Fluid/Lock

ATT. Succ. Crew #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Airway

 

 

Cardiac

IV/Medications

Basic Life Support

None

 

Nasal Airway

Sz. _____

Intubated (ETT)

ECG Monitoring

IV Access

Bleeding Control

Splint Extremety

Asst Vent.

RPM ______

Oral Airway

Sz. _____

Ventilator

External Pacing

IO Access

Burn Care

Splint Traction

O2

Cannula

LPM ______

Suction

 

Crichothyrotomy

R _____ M _____

IV Fluids

Glucose Check

Spinal Immob.

O2

Mask

LPM ______

Supraglottic Airway

NG Tube

Defib/Cardioversion

Medications

OB Care

Other

O2 Neb/BB

LPM ______

CPAP

 

Chest Decomp

CPR

 

 

 

Physician Note:

 

Func.

 

Printed Name

 

 

Signature

 

 

VA. Certification No.

 

 

 

 

AIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FR EMT Enh. Int. P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician's Signature/Printed Nam

DEA#

Drug Box #1

Drug Box #2

Narcotics Accounted For:

 

 

 

 

 

 

 

 

 

 

 

 

 

Old

 

Old

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New

 

New

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* This form is not intended for use as a full EMS medical record

How to Edit Ems Medical Record Form Online for Free

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Part # 1 of submitting epcr form online

2. Now that this part is finished, you should insert the essential particulars in s n g i, l a t i, t n e m s s e s s A, t n e m t a e r T, e v i t a r r a N, Gluc, Time LOC A V P U na LOC A, Time, Gluc, Pulse, Resp, SpO, Pain, ECG, and Time so that you can progress further.

epcr form online completion process explained (portion 2)

When it comes to e v i t a r r a N and t n e m t a e r T, be certain you get them right in this current part. Both of these are viewed as the most important fields in the file.

3. In this stage, review s e r u t a n g i S, Physician Note, Func, AIC, Printed Name, Signature, VA Certification No, FR EMT Enh Int P, Physicians SignaturePrinted Nam, DEA, Drug Box, Drug Box, Narcotics Accounted For, This form is not intended for use, and Old. These must be filled in with utmost accuracy.

Part no. 3 of submitting epcr form online

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