Irish Ambulance Patient Care Report Form PDF Details

The Irish Ambulance Patient Care Report form is a comprehensive document used by ambulance services to record vital details during emergency response situations. It includes various sections such as agency name, incident number, response times, and personnel involved, ensuring a structured approach to documenting the complexity of care provided. The form captures all aspects of the incident, from the initial dispatch call through to the patient's arrival at the destination, including response information like the number of patients, any mass casualty incidents (MCI), and details on the attending crew. Additionally, it provides space to record critical patient information, medical history, incident specifics, initial assessment, treatments administered, and the eventual patient outcome. This thorough record-keeping aids in continuity of care, facilitates accurate billing, and ensures compliance with regulatory requirements. It also helps in reviewing the response to incidents for quality improvement purposes. The integration of factors affecting care, such as environmental conditions and potential barriers to patient care, alongside detailed records of any pre-existing conditions, medications, and allergies, underscores the form's role in fostering patient-centered care in emergency medical services.

QuestionAnswer
Form NameIrish Ambulance Patient Care Report Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other names1099 reporting non reporting chart, patient care report template, printable ambulance report, ambulance patient care report form

Form Preview Example

Ambulance Patient Care Report

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Chief Complaint

 

Patient Chief Complaint

 

Primary Organ

 

 

 

Description

 

 

 

 

 

 

 

 

Onset Date / Time

 

 

 

 

 

 

 

 

 

 

 

 

System Affected

 

 

 

 

 

 

 

 

 

 

 

 

Cardiovascular

 

 

 

 

Signs & Symptoms (Select All That Apply)

 

 

 

 

CNS/Neuro

P S

Abdominal Pain

P S

Chest Pain

 

P S

Fever

 

P S

Palpitations

Endocrine/Metabolic

 

 

 

 

 

 

GI/Abdomen

 

Back Pain

 

 

Choking

 

 

Malaise

 

 

Rash/Itching

Global/Other Illnesses

 

Behavioral/Psych

 

Death

 

 

Mass/Lesion

 

Swelling

Musculoskeletal/Injury

 

Bleeding

 

 

Device/Equipment Problem

 

Nausea/Vomiting  

Weakness

OB/GYN

 

Breathing Problem

 

Diarrhea

 

 

None

 

 

Wound

Psych/ Behavioral

 

Change in Resp

 

Drainage/Discharge

 

Pain

 

 

 

 

Respiratory

 

 

 

 

 

 

 

 

 

 

 

 

Renal/GU Problems

 

 

 

 

Cause of Injury (Select One)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin

Injury Present

Aircraft Crash

Machinery Accidents

 

 

 

 

Yes

 

Assault

 

Mechanical Suffocation

 

 

 

Injury Description

 

No

 

Bicycle Crash

MV, Non-Traffic Crash

Identify the area of injury with

 

 

 

Bites

 

MV, Traffic Crash

 

the following numbers

 

Injury Intent

 

 

 

Chemical Poisoning

Motorcycle Crash

 

1

Amputation

 

 

Intentional, Other

Child Battering

Non-Motorized Vehicle Crash

2

Bleeding-Controlled

 

(Assaulted)

Drug Poisoning

Pedestrian Traffic Crash

3

Bleeding-Uncontrolled

 

Intentional, Self

Drowning

 

Radiation Exposure

4

Burn

 

 

Unintentional

Electrocution (Non-Lightning) Sexual Assault / Rape

5

Crush

 

 

 

 

Excessive Cold

Smoke Inhalation

 

6

Dislocation/Fracture

 

Mechanism

 

 

Excessive Heat

Stabbing/Cutting (Assault)

7

Gunshot

 

 

Blunt

 

Falls

 

Stabbing/Cutting (Accidental)

8

Laceration

 

 

Burn

 

Fire and Flames

Strike Blunt/Thrown Obj.

9

Pain without swelling/bruising

 

Other

 

Firearm Assault

Unarmed Fight/Brawl

10 Puncture/Stab

 

Penetrating

Firearm Injury (Accidental)

Venomous Stings

 

11 Soft Tissue swelling/bruising

 

 

 

Firearm (Self Inflicted)

Water Transport Crash

 

 

 

 

 

Lightning

 

 

 

 

 

 

 

 

 

Initial Assessment

 

 

 

 

 

 

 

 

 

 

 

 

Level of Responsiveness

Airway

 

 

 

 

Breathing

 

 

 

 

 

 

 

Circulation

 

 

Alert

 

 

Patent

 

Rate

 

Quality

L

Lung Sounds

R

 

Color

 

Temp

 

Condition

Cap Refill

Verbal

 

 

Non Patent

< 10

 

Normal

Clear

 

 

Normal

 

Normal

Normal

< 2 sec

Painful

 

 

Action taken:

 

10-24

 

Labored

Wet

 

 

Cyanotic

Hot

Diaphoretic

2 - 4 sec

Unresponsive

 

 

 

 

> 24

 

Fatigued

Wheezes

 

 

Pale

 

Cool

Dry

> 4 sec

 

 

 

 

 

 

Apneic

 

Absent

Diminished

 

 

Flush

 

Cold

 

 

 

Absent

 

 

 

 

 

 

 

 

Not Assessed

Absent

 

 

 

 

 

 

 

 

 

 

 

Alcohol/Drug Use

 

 

 

 

Glasgow Coma Score

 

 

 

 

 

 

 

Pupils

 

 

Barriers to Patient Care

Alcohol/Drugs

Eye Opening

 

Verbal

 

 

Motor

 

Time

 

 

 

 

L

 

 

R

Developmentally

 

4 Spontaneous

5 Oriented

 

6 Obeys Commands

 

 

 

 

 

 

 

Impaired

 

 

at Scene

 

 

 

 

 

 

Reactive

 

 

 

 

 

 

 

 

 

Hearing Impaired

 

Patient Admits

3 To Speech

 

4

Confused

 

5

Localized Pain

 

 

 

Score

Sluggish

 

Alcohol Use

 

2 To Pain

 

3

Inappropriate

4

Withdraws to Pain

 

 

 

 

Constricted

Language

 

Patient Admits

1 Not at All

 

2

Words

 

3

Flexion to Pain

Time

 

 

 

 

Physically Impaired

Drug Use

 

 

 

 

Inappropriate

2

Extension to Pain

 

 

 

 

Dilated

Physically Restrained

Smell of Alcohol

 

 

 

 

Sounds

 

1 None

 

 

 

 

Score

Nonreactive

Speech Impaired

 

None

 

 

 

 

1 None

 

 

 

 

 

 

 

 

 

 

 

Unattended or

 

Allergies NKA

 

 

Patient’s Medications

 

 

 

 

 

 

 

 

 

 

 

 

Unsupervised (Including

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minors)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unconscious

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

 

 

Time

BP

 

Pulse

Resp

 

Rhythm

SpO2

Procedures

 

# Attempts

Success

Medication

Dose

Route

Response

Crew #

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

Improved

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

Worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

Unchanged

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

Improved

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

Worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

Unchanged

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

Improved

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

Worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

Unchanged

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

Improved

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

Worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

Unchanged

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

Improved

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

Worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

Unchanged

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

Improved

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

Worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

Unchanged

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

Improved

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

Worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

Unchanged

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

Improved

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

Worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

Unchanged

 

Cardiac Arrest Information

Cardiac Arrest

No

Yes:

After EMS Arrival

Prior To EMS Arrival

Etiology

Drowning

Electrocution

Presumed Cardiac

Respiratory

SIDS

Trauma

Other

Resuscitation Attempted

No:

Circulation Restored by First Responder

DNR Orders

Obvious Death

Yes:

CPR Only

Defibrillation

Time of Arrest Before EMS

0-2 min. 8-10 min.

2-4 min. 10-15 min.

4-6 min. 15-20 min.

6-8 min. > 20 min.

Unknown

Witnessed By

Not Witnessed

Healthcare Provider

Lay Person

Return of Circulation

No

Yes:

Prior to ED Arrival Only

Prior to ED Arrival and at the ED

Resuscitation Discontinued

Time :

Reason Discontinued

DNR

Medical Control Order

Obvious Death

Policy Requirements Completed

Return of Circulation

First Cardiac Rhythm

 

 

 

 

 

Asystole

Normal Sinus Rhythm Ventricular Tachycardia

Unknown AED Non-Shockable Rhythm

Other

Bradycardia

PEA

Ventricular Fibrillation

Unknown AED Shockable Rhythm

 

 

 

 

 

 

Cardiac Rhythm At Destination

 

 

 

 

12 Lead ECG:

 

Atrial Fibrillation/Flutter

Left Bundle Branch Block

Right Bundle Branch Block

Torsades de Pointes

Anterior Ischemia

AV Block:

Normal Sinus Rhythm

Sinus Arrhythmia

Ventricular Fibrillation

Inferior Ischemia

1st Degree

Paced Rhythm

 

Sinus Bradycardia

Ventricular Tachycardia

Lateral Ischemia

2nd Degree-Type 1

PEA

 

Sinus Tachycardia

Unknown:

Septal Ischemia

2nd Degree-Type 2

Premature:

 

ST-Elevation

AED Non-Shockable Rhythm

Agonal/Idioventricular

3rd Degree

Atrial Contractions

Supraventricular Tachycardia

AED Shockable Rhythm

Artifact

 

Junctional

Ventricular Contractions

 

Other

Asystole

 

 

 

 

 

 

Patient Past Medical HIstory

Narrative

Medical Control Method

Standing Orders On-line

On Scene

Written Orders (Patient Specific)

 

 

Airbag Deployment

 

HIPAA

 

 

 

Airbag Deployed Front

Airbag Deployed Other

Airbag Not Present

Notice of HIPAA Privacy Practices

Airbag Deployed Side

Airbag Not Deployed

 

 

given to patient per agency guidelines

 

 

 

 

 

 

EMD Performed

 

 

Safety Equipment

 

No

Child Restraint

Helmet Worn None

Personal Floatation Device

Protective Non-Clothing Gear

Yes, With Pre-Arrival Instructions

Eye Protection

Lap Belt

Other Protective Clothing Gear

Shoulder Belt

Yes, Without Pre-Arrival Instructions

 

 

 

 

 

 

 

 

 

 

Signatures

 

Receiving RN/MD

Guardian

I Refuse Treatment/Transport (Also See Back)

Technician

Continued On Supplement

Disclaimer: This page is provided for optional use by the ambulance provider; it is not required by the Minnesota EMS Regulatory Board.

 

Billing Information

 

 

 

Medicare Number

Medicaid Number

Other

Primary Insurance

Company Name

 

Insurance Number

 

 

Group Number

 

 

 

 

 

 

 

 

 

 

Insured Last Name

Same as Patient’s

Insured First Name

Same as Patient’s

M.I.

 

Relationship To

Self

 

 

 

 

 

 

 

Patient

Spouse

 

 

 

 

 

 

 

 

Parent/Guardian

Address

Same as Patient’s

City

County

State

Zip Code

 

Home Phone

Secondary Insurance

Secondary Insurance Company Name

Secondary Insurance Number

 

 

 

Group Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insured Last Name

Same as Patient’s

Insured First Name

 

Same as Patient’s

 

M.I.

 

Relationship To

Self

 

 

 

 

 

 

 

 

 

 

Patient

Spouse

 

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian

Address

Same as Patient’s

City

 

County

 

State

 

Zip Code

 

Home Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Private Insurance Workers Comp Medicare

Medicaid

HMO/PPO

Contract Services

 

Authorization For Billing

I authorize the release to the Social Security Administration and Centers for Medicare and Medicaid Services, any HMO/PPO, other private or public insurance, or their agents, fiscal intermediaries or carriers or an independent agency performing billing or collection functions on behalf of the ambulance service, any personal, medical or billing information needed for this or a related claim. I understand I will be responsible for any services that are not paid/covered by my insurance. A copy of this authorization shall be valid as the original and shall remain in effect until revoked in writing by the patient/insured. I request payment of medical insurance benefits either to me or to the ambulance service.

Signature

Date

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I was provided with a copy of the ambulance services “Notice of Privacy Practices.”

Signature

Date

 

 

 

 

Name Printed

Relationship To

Self

 

Patient

Spouse

 

 

Parent/Guardian

Waiver of Liability

I refuse treatment and/or transportation by the providing ambulance service. I assume responsibility for my own, my child’s, or any family member’s medical treatment. I have been advised to seek the atten- tion of a physician. I release the providing ambulance service, its employees, officers and directors from liability resulting from my own, my child’s, or any other family member’s refusal of medical treatment or transportation.

Signature

If Signing For A Minor

Date

Signature

Date

 

 

 

 

Name Printed

Relationship To

Parent/Guardian

 

Patient

 

Patient’s Belongings

Patient’s Belongings

Location of Belongings

Who Belongings Were Left With