Irish Ambulance Patient Care Report Form – Fill Out and Use This PDF

Agency Name

Date of Incident

Call Number

Incident Number

Response Times

Response Information

Personnel

Driver

PSAP Call

Arrive Scene

In Service

PCR Number

Starting Mileage

Attendant

 To Scene

1

 To Dest.

Dispatch Notified

Arrive Patient

Unit Cancelled

# of Patients

MCI

At Scene Mileage

Attendant

 To Scene

2

 Yes

 To Dest.

 No

Unit Dispatched

Leave Scene

In Quarters

Responding Unit

Dest. Mileage

Attendant

 To Scene

3

 To Dest.

Enroute

Arrive Dest.

Crew Number

Ending Mileage

Attendant

 To Scene

4

 To Dest.

Incident Information

First Responder Agencies

Incident Address

Room/Apt

Factors Affecting Care

 Amb. Crash

 Diversion

 Safety

City

County

State

Zip Code

 Amb. Failure

 Extrication

 Traffic

 Crowd

 HazMat

 Weather

Type of Location

 Directions

 Language Barrier

 None

 Airport

 Home/Residence

 Mine or Quarry

 Residential Institution  Other

 Distance

 Staff Delay

 Other

 Farm

 Industrial Place

 Place of Sport

 Street or Highway

 Healthcare Facility  Lake, River

 Public Building

 Trade or Service

Destination/Hospital Name

Facility Diverted From

Response Request

To

Response Mode

From

Disposition

 Response (Scene)



Lights and Siren



Treated:

 Interfacility Transfer



No Lights or Siren



 Transported by EMS

Destination Determination

 Closest Facility

 Specialty Resource Ctr.

 Medical Transport

 Transferred Care

(Scheduled)

Initial No Lights and Siren

 Released

 Protocol Guideline

 Law Enforcement Choice

 Standby



Upgraded to Lights and Siren



 Patient/Family Choice  Diversion

 Intercept

 Cancelled

Initial Lights and Siren

Destination Type

 Mutual Aid





 Patient Refused Care

 Hospital

 Ground Ambulance

Downgraded to No Lights and Siren

 Dead at Scene

 Home

 Police/Jail

 Medical Office/Clinic

 Morgue

Patient Information

 Nursing Home

 Other

Last Name

First Name

M.I.

 Air Ambulance

Primary Role of Unit

Address

Room/Apt

 ALS Ground

 Non-Transport

 BLS Ground

 Other Transport

 Critical Care Ground

 Rescue

City

County

State

 ERU

 Rotor Craft

 Fixed Wing

 Supervisor

Zip Code

Phone Number

KG

Gender

Dispatch Reason

(

)

-

LB

M / F

 Abdominal Pain

 Heart Problem

 Allergies

 Heat/Cold Exposure

Social Security Number

DOB

Age

 Animal Bite

 Hemorrhage/Laceration

-

-

/

/

 Assault

 Industrial Accident

Patient Physician

Guardian Name

 Back Pain

 Ingestion/Poisoning

 Breathing Problem

 MCI

 Burns

 Medical Transport

Race

Ethnicity

 Cardiac Arrest

 Pain

 American Indian or Alaska Native

 Asian

 Hispanic or Latino

 Chest Pain

 Pregnancy/Childbirth

 Black or African American

 White

 Not Hispanic or Latino

 Choking

 Psychiatric Problem

 Hawaiian or Other Pacific Islander

 Other

 CO Poisoning/Hazmat

 Sick Person

 Convulsions/Seizure

 Stab/Gunshot Wound

Prior Aid (Select All That Apply)

 AED - ERU

Airway:

Performed By

Outcome/Condition

 Diabetic Problem

 Standby

 AED - First Responder

 BVM

 EMS Provider

 Improved

 Drowning

 Stroke/CVA

 AED - Public Access

 Combitube

 Law Enforcement

 Worse

 Electrocution

 Traffic Accident

 CPR

 Nebulizer Treatment

 Lay Person

 Unchanged

 Eye Problem

 Traumatic Injury

 Extrication

 Spinal Immobilization

 Oxygen

 Other Healthcare Provider

 Fall Victim

 Unconscious/Fainting

 Splinting

 Suction

 Patient

 Headache

 Unknown Problem/Man Down

Provider Impression - Primary/Secondary (Select One For Each)

P S

P S

P S

P S

P

S

 

AAA

 

CHF

 

Hypotension

  Other CNS

  Seizure

 

Abdominal Pain/Prob.  

Dehydration

 

Hyperthermia

  Other Endocrine/Metabolic   Sexual Assault / Rape

 

Airway Obstruction

 

Diabetic hyperglycemia  

Hypothermia

  Other General Urinary

  Smoke Inhalation

 

Allergic Reaction

 

Diabetic hypoglycemia

 

Hypovolemia / Shock

  Other Illness/Injury

  Stings / venomous bites

 

Altered LOC

 

Electrocution

 

Inhalation Injury

  Other OB/Gyn

  Stroke / CVA / TIA

 

Asthma

 

ETOH Abuse

(toxic gas)

  Pain

  Substance Drug Abuse

 

Behavioral / Psych

 

Fever

 

OB Delivery

  Poisoning / drug ingest.

  Syncope / fainting

 

Bowel Obstruction

 

GI Bleed

 

OB/Pregnancy/Labor

  Respiratory Arrest

  Traumatic Injury

 

Cancer

 

Headache

 

Obvious Death

  Respiratory Distress

  Unconscious Unknown

 

Cardiac Arrest

 

Heat Exhaustion/Stroke  

Other Abdominal/GI

  Rhythm Disturbance

  Vaginal Hemorrhage

 

Chest Pain/Discomfort  

Hypertension

 

Other Cardiovascular