EMS Transfer Of Care Form PDF Details

Ensuring a seamless transition in emergency medical situations is vital for patient outcomes, and the EMS Transfer of Care form plays a crucial role in this process. This comprehensive document serves as a bridge between emergency medical services (EMS) providers and hospital or healthcare facility staff, containing essential information that supports continuity of care. Key elements of the form include patient demographics, such as name, address, and date of birth, alongside the EMS agency's details and incident specifics. The form goes further to detail the patient's chief complaint or provider's impression, a brief history or pertinent symptoms related to conditions like stroke, chest pain, trauma, or altered mental states. Time-sensitive information, such as the onset of symptoms and EMS contact times, are meticulously recorded. Moreover, the form includes an outline of the patient's physical exam findings, medications, known allergies, and vital signs at various times. It also captures EMS treatments and interventions, ensuring that receiving healthcare providers have a clear picture of the care already provided. Medication lists and copies of ECGs, when available, are attached to provide a comprehensive view of the patient's condition upon transfer. The form culminates in a certification section where EMS providers and receiving hospital or agency staff officially document the care transition. This formalizes the handoff and underscores the collaborative effort between pre-hospital and hospital-based teams. Overall, the EMS Transfer of Care form is an indispensable tool in emergency medical services, designed to enhance patient safety and improve outcomes by ensuring a smooth and informed transfer of care.

QuestionAnswer
Form NameEMS Transfer Of Care Form
Form Length1 pages
Fillable?Yes
Fillable fields103
Avg. time to fill out20 min 55 sec
Other namesems transfer of care form, pa ems transfer of care form, pa transfer of care form fillable, 12-lead

Form Preview Example

 

Patient Name

 

Address

EMS Transfer Of Care Form

City

EMS Agency Name / Affiliate Number

State Zip

Date

Time

Incident Number

Age

Gender (M / F)

Date of Birth

SSN

Incident Location:

Chief Complaint / Provider Impression:

BRIEF HISTORY / PERTINENT SYMPTOMS

For Stroke, Chest Pain, Trauma or Altered Mental Status

Time of Persistent Symptoms, Injury, or Last Seen Normal

DateTime

EMS Contact Time – First EMS ALS Contact Time

PERTINENT PHYSICAL EXAM FINDINGS

MEDICATIONS

NONE

ALLERGIES

NKDA

Patient Medications or Medication List Delivered with Report

Yes

VITAL SIGNS

Time

Pulse

Blood Pressure

Resp

Glucose

SaO2

Mental Status (AVPU)

 

 

 

 

 

 

Alert

Voice

Pain

Unresponsive

 

 

 

 

 

Alert

Voice

Pain

Unresponsive

 

 

 

 

 

Alert

Voice

Pain

Unresponsive

 

 

 

 

ECG

 

 

 

 

Rhythm:

 

12-lead ECG Interpretation

 

Copy of Rhythm Strip/ all 12-lead ECGs

 

 

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

Delivered with Report

Yes

 

 

 

 

 

 

EMS TREATMENT

 

NOTES / COMMENTS

 

Time

Medication/ Intervention

Dose

 

 

 

Yes

IV Fluid Type:

 

 

Size/Location:

 

Total IV Fluid Volume Given:

Oxygen:

 

IV

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

mL

LPM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER TRANSFERRING CARE

 

 

CERTIFICATION

 

 

CARE TRANSFERRED TO

 

 

 

 

NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QRS Provider

 

 

 

 

Receiving Hospital/Agency Name:

Time of Transfer

 

 

 

 

 

 

 

 

 

 

 

QRS Provider Signature:

 

 

 

 

 

 

 

 

EMS Provider

Receiving Healthcare Provider Signature:

EMS Provider Signature:

Signature:_______________________________________ (Print) ___________________________________

Bureau of Emergency Medical Services

VER. 22 APR 2014

JPT