North Dakota Ems Patient Care Report Form – Fill Out and Use This PDF

Disp Type

Service Name: (Please Print)

Level

North Dakota EMS Patient Care Report

Service #:

Unit #:

Incident #:

PCR #:

Date of Onset:

Time:

Date Incident Reported:

PCR Report Date:

Incident

/

/

:

/

/

/

/

Location

PSAP Time of Call

Arrive Patient

Starting Mileage

Patient name

:

:

Veh Type

Disposition

Dispatched

Depart Scene

At Scene Mileage

Street Address

:

:

Unit Role

Enroute

Arrive at Destination

Destination Mileage

City

State

Zip

To Scene

:

:

Arrived at Scene

Available

Ending Mileage

Phone

Date of Birth

Age

Factor 1

:

:

From Scene

Scene Address

Scene GPS Longitude:

Social Security Number

Sex

Scene GPS Latitude:

Factor 2

Inj Ind. 1

Scene City

State

Scene Zip

Scene County

Scene Township/FIPS

Receiving Agency

Chief Complaint

Pre-Existing Conditions

Allergies

Factor 3

Inj Ind. 2

Medications

Time

Pulse

BP

Resps

GCS

SaO2

EKG Interpretation

Signs and Symptoms

Factor 4

Inj Ind. 3

Narrative

Factor 5

Safety 1

Impression

Safety 2

Time

Medication

Route

Initial

Effect

Dest Type

Safety 3

Dest Det

Safety 4

Suspected

Safety 5

Cause 1

Prior Aid

Cause 2

Impact 1

Cause 3

Impact 2

Cause 4

Impact 3

Cause 5

Care Turned Over To:

Position

PROCEDURES

S = Successful

U = Unsuccessful

# of

# of

# of

TIME

TIME

TIME

1st CPR

ATTEMPTS

CREW #

S/U

ATTEMPTS

CREW #

S/U

ATTEMPTS

CREW #

S/U

Abdominal Thrusts

Delivery (OB)

Needle Thorac.

Auto Defib.

Demand Valve

NG Tube

Back Blows

EKG

Oropharyngeal Airway

Bag Valve Mask

Extrication

Oxygen Administered

1st Defib

Bandage

Full Spinal Immobilization

Pacing

Bleeding Controlled

Intubation - multi-lumen airway

Pocket Mask

Blood Draw

Intubation Nasotrachial

Splint - Extremity

Blood Gluc. Level Check

Intubation Oro Tracheal

Splint - Traction

Shocks

Blood Product Admin.

Irrigation

Suctioning

Burn Care

IV Centra Vein

Surgical Airway

Cardiovert

IV Intraosseous

Tourniquet

Cervical Collar

IV Peripheral

Urinary Cath.

Race

Cold Pack

MASTApplied

Ventilator

CPR

MASTInflated

Other

Defib - Manual

Nasopharyngeal Airway

Not Applicable *

BILLING INFORMATION

MILEAGE

INSURANCE TYPE

Insurance - Primary

Number:

Insurance - Secondary

Number:

Beg:

❏ No Insurance

❏ Private Pay

Responsible Party:

End:

❏ Private Insurance

❏ Medicare

(Last Name)

(First Name)

(MI)

Total:

❏ Medicaid

❏ Medicare/Medicaid

(Address)

❏ VA Insurance

❏ Unknown

(City)

(State)

(Zip)

(Phone)

❏ Not Applicable

RECEIPT OF SERVICE

REFUSAL OF SERVICE

I acknowledge receipt of the EMS services listed in this document and accept

This is to certify that I am refusing treatment / transport. I have been informed

full responsibility for all charges. I authorize payment of medical benefits from

of the risk(s) involved, and hereby release the ambulance service, its atten-

my insurance company to provide of such services and authorize the provider

dants, and its affiliates, from all responsibility which may result from this action.

to release medical and other necessary information to my insurance company

for that purpose.

Patient Signature

Date/Time

Patient Signature

Date/Time

CREW

CREW MEMBER NAMES

STAFF ID

DRIVER

LEVEL

1

Y

N

2

Y

N

3

Y

N

4

Y

N