Commonwealth of Virginia EMS Medical Record - Short Form at a glance
What it is: Commonwealth of Virginia EMS Medical Record - Short Form: Patient History, Patient and Response Information, Assessment/Vital Signs, Medication Administration, Airway/Intravenous Procedures, Signatures Narrative.
Who signs: Under Signatures, enter the Printed Name, the VA. Certification No. and the Signature, and SIGN.
A filled-in Commonwealth of Virginia EMS Medical Record - Short Form example: a crew member records one call
How to fill out Commonwealth of Virginia EMS Medical Record - Short Form, box by box
Agency, Unit # and Date, Location and Incident #
Enter the Agency, Agency #, Unit # and Date, the Date as D D / D D / Y Y.
Under Patient and Response Information, enter the Location and the Incident #.
Patient and Response Information
Under Patient and Response Information, enter the Name, Age, Address, Telephone, City, State and ZIP.
Next of Kin
Under Next of Kin, enter the Name, Rel. and Tel.#.
Times (24hr Format)
Enter the Times (24hr Format) for PSAP Time, Unit Disp., Enroute, Arrive Scene, Arrive Patient, Leave Scene and Arrive Dest.
Chief Complaint and Duration, Secondary Complaint and Duration and Symptoms
Enter the Chief Complaint and Duration, the Secondary Complaint and Duration and the Symptoms.
Signatures
Under Signatures, enter the Printed Name, the VA. Certification No. and the Signature, and SIGN.
More rules for Commonwealth of Virginia EMS Medical Record - Short Form
Under Assessment/Vital Signs, enter the Time, LOC, Resp., B/P, Pulse, SpO2, Pain, ECG, Gluc., CO2 and Defib Joules.
Under Medication Administration, enter the Time, Medication, Dose, Route and Crew #.
Common questions about Commonwealth of Virginia EMS Medical Record - Short Form
When is this form not the right one?
This form is not intended for use as a full EMS medical record.
Sources
[1] Commonwealth of Virginia EMS Medical Record - Short Form, Virginia Department of Health (the Official source link on this page).