The Emergency Medical Services (EMS) Transfer of Care Form is a document used to ensure the continuity of patient care during an emergency medical transport. The form must be completed by the EMS providers who are transferring care of the patient to another provider. The form includes information about the patient's condition, medications, and other important details. It is important to complete the form properly in order to avoid any gaps in patient care. In this blog post, we will discuss the importance of completing the EMS Transfer of Care Form properly. We will also provide a detailed explanation of how to complete the form correctly. Finally, we will provide an example of how to use the form in practice. Thanks for reading!
| Question | Answer |
|---|---|
| Form Name | Ems Transfer Of Care Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ems transfer of care form, pa transfer of care form fillable, SaO2, SSN |
|
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: |
|
|
Copy of Rhythm Strip/ all |
|||||
|
|
|
|
: |
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
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 |