Patient Care Report Form PDF Details

When it comes to delivering top notch healthcare, it is important for medical professionals to properly document patient information. This not only helps ensure that the most accurate diagnosis is given, but also provides a powerful tool to track progress and findings during the care process. A Patient Care Report Form (PCRF) is an essential resource used by medical prescribers and clinicians to record informaion pertinent to a specific patient's care. The information collected through PCRFs provide valuable insights into the effectiveness of treatment plans and help facilitate optimal outcomes for patients throughout their healing journey. In this blog post, we’ll explore what a PCRF entails, how it can be used in hospital settings, its role within the larger professional landscape of medicine, and more!

QuestionAnswer
Form NamePatient Care Report Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesems pcr template, ems run report, iowa patient report, ems run report example

Form Preview Example

Motor Component

Corporate Express 13-984110-01 MF3 12To reorder call 800-397-8309

SERVICE NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Care Report

(PLEASE PRINT)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service #:

 

 

 

Unit #:

 

 

 

Incident #:

 

 

 

 

 

Pt. Record #:

 

 

 

 

 

 

Crash #:

 

 

 

 

 

 

 

 

 

Date of Onset:

 

 

 

 

 

 

Date Unit Notified:

 

 

 

 

 

Run Report Date:

 

 

 

 

Trauma ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dispatched For:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIMES (MILITARY)

 

 

 

 

 

 

 

 

 

 

PATIENT INFORMATION

 

 

 

 

 

 

 

 

 

Dispatch

 

 

 

Time Left

(Last Name)

 

 

 

(First)

 

 

 

 

 

 

 

 

 

 

 

 

(MI)

Notified:

 

 

 

Scene:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unit Notified:

 

Arrived at Destination:

(Street Address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Apt. #)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unit Enroute:

 

 

Back In Service:

(City)

 

 

 

(State)

 

 

 

 

 

 

 

 

 

 

 

 

(Zip Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Arrived at Scene:

 

Total Incident Time:

(Phone)

 

 

 

(Date of Birth)

 

 

 

 

 

 

 

 

 

 

 

 

(Age yrs. mons)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minutes For Response:

 

 

 

 

911

 

YES

Time of Injury/Illness:

(Gender)

M 1

F 2

Unk 3

 

(SSN#)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

-

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minutes At Scene:

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity

 

Race

0 Other, including multi racial

 

3 American Indian, Eskimo or Aleut

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0 Other

 

 

 

1 White

 

 

 

4 Asian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minutes For Transport:

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Hispanic

 

 

 

2 Black

 

 

 

U Undetermined

 

 

 

 

 

 

 

 

 

Chief Complaint:

 

 

 

 

 

 

 

 

 

 

 

 

 

Injury/Illness Narrative:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Past Medical History:

Pertinent Findings on Physical Exam:

Allergies:

Patient Medications:

Emerg. Med. Care Given:

Patient Response to Emerg. Med. Care:

Provider Impression: - Select one

Abdominal Pain/Problems

Airway Obstruction

Alleged Sexual Assault

Allergic Reaction

Altered Level of Consciousness Behavioral Disorder

Cardiac Arrest

Cardiac Rhythm Disturbance

Chest Pain/Discomfort

Diabetic Symptoms

Electrocution

Hyperthermia

Hypoglycemia

Hypothermia (Disease)

Hypothermia (Trauma) Hypovolemia

Inhalation Injury (Toxic Gas)

Not Applicable

Obvious Death

Other

Poisoning/Drug Ingestion

Pregnancy/OB Delivery

Psychiatric Disorder

Respiratory Arrest

Respiratory Distress

Seizure

Shock

Smoke Inhalation

Stings/Venomous Bites

Stroke/CVA

Syncope/Fainting

Traumatic Hypovolemia

Traumatic Injury

Vaginal Hemorrhage

Unknown

Mutual Aid

EMS Tier

Destination / Transferred To

MODE OF TRANSPORT

Fixed Wing

Ground

None

Other

Rotor Craft

Closest Facility

Diversion

Family Choice

Law Enforcement Choice

DESTINATION DETERMINATION/OUT OF HOSPITAL TRIAGE CRITERIA

Managed Care

Other

Protocol

Not Applicable

Patient Choice

Specialty Resource Center

On-LIne Medical Direction

Patient Physician Choice

Trauma Triage (Anatomy of Injury)

Trauma Triage (GCS, Vitals)

Trauma Triage (Mechanism of Injury)

Trauma Triage (Risk Factors)

Unknown

CLINICAL INFORMATION

 

 

 

 

 

Pulse

Glasgow Coma Scale

Revised Trauma Score

Revised Trauma Score

 

Respiratory Effort

 

Resp. Sounds

Time

B/P

PULSE

RESP

TEMP

O2

Eye Verb Motor Total

 

(RTS)

 

Pediatric

1

Normal

N Not Assessed

L

Clear

R

 

 

 

 

 

 

 

 

 

 

Resp BP GCS Total

Resp BP GCS Total

 

 

 

 

 

 

 

 

 

 

2

Shallow/Labored

U Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

Bronchi

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

Shallow/Non-Labored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

Deep/Labored

 

 

 

Rhales

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

Deep/Non-Labored

 

 

 

L

Wheezes

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

Absent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

Labored/Fatigued

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin Perfusion:

 

 

 

Pupils:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Normal

 

L

 

Normal

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

Constricted

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2 Decreased

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

Dilated

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 Not Assessed

 

L

No react.

R

 

Eye Opening

Verbal Component

 

Glasgow Coma Scale (GCS) Values

 

 

 

 

Component

For patients >5 years:

For patients 2-5 years:

For patients 0-23 months:

0

Not applicable

1

None

2

Non-specific sounds

1

None

1

None

1

None

3

Inappropriate words

2

Grunts

2

Persistent cry, grunting

2

Responds to Pain

4

Confused conversation or

3

Cries and/or screams

3 Inappropriate cry

3

Responds to Speech

 

speech

4

Inappropriate words

4

Cries, inconsolable

4

Spontaneous Opening

 

5

Oriented and appropriate

5

Appropriate words

5

Smiles, coos, cries

 

 

 

 

 

speech

9

Not assessed

 

appropriately

 

 

9

Unknown

 

 

9

Not assessed

For patients >5 1 None

2 Extensor posturing in response to painful stimulation

3 Flexor posturing in response to painful stimulation

4 General withdrawal in response to painful stimulation

5 Localization of painful stimulation

6 Obeys commands with appropriate motor response

9 Unknown

For patients up to 5 years 1 None

2 Extensor posturing in response to painful stimulation

3 Flexor posturing in response to painful stimulation

4 General withdrawal in response to painful stimulation

5 Localization of painful stimulation

6Spontaneous

9 Not assessed

 

Revised Trauma Score (RTS) Values

 

Resp. Rate

Systolic B.P.

GCS Total

10-29

4

BP>89 4

13-15

4

>29

3

76-89

3

9-12

3

6-9

2

50-75

2

6-8

2

1-5

1

1-49

1

4-5

1

NONE

0

NONE

0

< 4

0

Cardiac Arrest Information

Cardiac Arrest:

Y

N

Bystander CPR:

Y

N

Witnessed Arrest:

Y

N

Pulse Restored:

Y

N

Trauma Arrest:

Y

N

Number of Shocks:

 

 

 

 

 

 

 

 

Cardio Pulmonary

Arrest Time:

Min.

<4

<8

<12

>12

Unk.

Arrest to CPR:

 

 

 

 

 

Arrest to DEFIB.

 

 

 

 

 

Arrest to Meds.

 

 

 

 

 

 

 

 

 

 

 

Cardiac Rhythm: I = Initial D = Destination

PLEASE NOTE: ANY CHANGES IN CARDIAC RHYTHM SHOULD BE NOTED BELOW BY (

I

D

Time rhythm observed

I

D

Time rhythm observed

I

D

Time rhythm observed

I

D

Time rhythm observed

 

 

 

Not Applicable

 

 

 

AV Block - 1st

 

 

 

PEA (EMD)

 

 

 

PVCs

 

 

 

Unable to Identify

 

 

 

AV Block -2nd, Type I

 

 

 

Idioventricular

 

 

 

Sinus Bradycardia

 

 

 

Asystole

 

 

 

AV Block -2nd, Type II

 

 

 

Junctional

 

 

 

Sinus Rhythm

 

 

 

Atrial Fibrillation

 

 

 

AV Block - 3rd

 

 

 

Pacemaker

 

 

 

Sinus Tachycardia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIME COLUMNS)

I

D

Time rhythm observed

 

 

 

ST Elevation/Abnormal

 

 

 

SVT

 

 

 

Vent. Fibrillation

 

 

 

Vent. Tachycardia

 

 

 

Other

 

 

 

 

 

 

 

Date:

Signature

Page 1

FLIP OVER TO BEGIN PAGE 2

34

SERVICE NAME:

 

 

 

 

 

 

(PLEASE PRINT)

 

 

 

 

 

 

Service #:

Unit #:

 

Incident #:

 

Pt. Record #:

Crash #:

Date of Onset:

 

Date Unit Notified:

 

Run Report Date:

Trauma ID #:

 

 

 

 

 

 

 

Abrasion

Amputation

BluntInjury

Burn

CrushingInjury

Dislocation/Fracture

GunshotWound

INJURY

MATRIX

Select one

Head

Face

Neck

Chest

Back

Abdomen

Pelvic / Genitalia

Upper Extremity

Lower Extremity

Time

# of Attempts Staff ID Staff ID S/U

Assisted Ventilation (Positive Pressure)

Bleeding Controlled

Burn Care

Cardiopulmonary Resuscitation

Cervical Immobilization

Combination Airway/EOA

Combination Airway/ET

Cricothyrotomy

ECG Monitoring

Endotracheal Intubation

Esophageal Airway

INJURY

Laceration

Pain

Puncture/Stab

TissueSwelling

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accidental Drug Poisoning

 

 

 

Mechanical Suffocation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cause of Injury

 

- Select one

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Accidental Chemical Poisoning

 

 

 

Motor Vehicle Non-traffic Crash

 

 

 

 

 

 

 

 

 

 

 

 

Accidental Falls

 

 

 

 

 

 

 

Vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aircraft Related Accident

 

 

 

Motorcycle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alleged Sexual Assault

 

 

 

Motorcycle/Vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bicycle

 

 

 

 

 

 

 

Not Applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bicycle Accident

 

 

 

Radiation Exposure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bites

 

 

 

 

 

 

 

Smoke Inhalation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Battering

 

 

 

 

 

 

 

Snowmobile

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Drowning

 

 

 

 

 

 

 

Stabbing Assault

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Electrocution (Non-lightning)

 

 

 

Vehicle/Bicycle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Excessive Cold

 

 

 

 

 

 

 

Vehicle/Fixed Object

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Excessive Heat

 

 

 

 

 

 

 

Vehicle/Pedestrian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fire and Flames

 

 

 

Vehicle/Train

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Firearm Assault

 

 

 

 

 

 

 

Vehicle/Vehicle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Firearm Injury (Accidental)

 

 

 

Venomous stings (plants, animals)

 

 

 

 

 

 

 

 

 

 

 

 

Firearm Self-inflicted (Intentional)

 

 

 

Water transport accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lightning

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Machinery Accidents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROCEDURES

S = Successful

U = Unsuccessful

 

 

 

 

Time

 

 

 

 

 

 

 

 

# of Attempts

 

Staff ID Staff ID S/U

 

Time

 

# of Attempts

Staff ID Staff ID S/U

 

 

 

 

External Cardiac Pacing

 

 

 

 

 

 

 

 

Needle Thoracotomy

 

 

 

 

 

 

 

 

 

External Defibrillation (includes auto)

 

 

 

 

 

 

 

 

Obstetrical Care (Delivery)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Glucometer

 

 

 

 

 

 

 

 

 

Oropharyngeal Airway Insertion

 

 

 

 

 

 

 

 

 

Intraosseous Catheter

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intravenous Catheter

 

 

 

 

 

 

 

 

 

Oxygen by Cannula

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intravenous Fluids

 

 

 

 

 

 

 

 

 

Oxygen by Mask

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Long Spineboard

 

 

 

 

 

 

 

 

 

Pulse/Oximeter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAST (PASG)

 

 

 

 

 

 

 

 

 

Short Spine Board (KED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monitoring a Medicated IV

 

 

 

 

 

 

 

 

Suction

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nasogastric Tube Insertion

 

 

 

 

 

 

 

 

Splint of Extremity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nasopharyngeal Airway Insertion

 

 

 

 

 

 

 

 

Traction Splint

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICATIONS

Medication:

Time:

Dosage:

Route:

Staff ID:

Comments/

Response:

 

SCENE INFORMATION

Scene Address:

Apt. #:

Scene City:

Scene State:

Scene Zip:

Scene County:

Scene Township:

Location Type:

Not Applicable

Other

Unknown

Medical Facilities

Doctor’s Office/Clinic

Hospital

Nursing Home

Other Medical Facility

Residences

City Residence

Farm Residence

Other Residence

Road/Highway Areas

Freeway Gravel Road Highway (County) Highway (State) Interstate (55 mph) Interstate (65 mph) Other Roadway Street

Job/Construction Site

Construction Site

Farm

Manufacturing Facility

Office Building

Other Job Site

Water/Waterways

Lake/Pond

Other Water Area

Quarry/Pit

River/Stream

Swimming Pool

Public Places

Government Building

Other Public Place

Recreation Area

Shopping Center

Educational Institutions

College/University

Grade School

High School

Jr. High/Middle School

Other School

Preschool/Daycare

Factors Affecting EMS:

Adverse Road Conditions

Adverse Weather

Crowd Control

Hazardous Material

Language Barrier

None

Not Applicable

Other

Prolonged Extrication (>20 min)

Unsafe Scene

Vehicle Problems

Lights

To

From

To

From

To

From

Scene

Scene

Scene

Scene

Scene

Scene

&

 

Initial non-emergent, upgraded

 

Non emergent, No Lights or Siren

 

Initial emergent, downgraded to no Lights or Siren

Siren:

 

to Lights or Siren

 

Emergent, with Lights or Siren

 

Not Applicable

Page 2

FLIP OVER TO BEGIN PAGE 3

5

SERVICE NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(PLEASE PRINT)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service #:

Unit #:

 

Incident #:

 

 

 

 

 

Pt. Record #:

 

 

 

Crash #:

Date of Onset:

Date Unit Notified:

 

 

 

 

 

Run Report Date:

 

Trauma ID #:

TREATMENT AUTHORIZATION

 

 

 

 

 

 

 

 

 

 

 

PRIOR AID

 

 

 

 

 

None

 

None

 

 

 

 

EMS Agency/Fire Dept

 

 

 

Health Care Professional

 

 

Medical Facility

 

Not Applicable

 

 

 

 

 

Ambulance Service

 

 

 

EMT

 

 

 

 

Doctor’s Office/Clinic

Not Applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

On-Line Designee

 

Other

 

 

 

 

 

First Responder Service

 

 

 

First Responder

 

 

Hospital

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

On-Line Physician

 

Unknown

 

 

 

 

 

Fixed Wing Service

 

 

 

Other Medical Professional

 

 

Nursing Home

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

Helicopter Service

 

 

 

Physician

 

 

Other Medical Facility

 

Citizen/Bystander

 

 

 

 

 

 

 

 

 

Physician at Scene

 

 

 

 

Other Agency/Fire Dept

 

 

 

RN/LPN

 

 

Law Enforcement

 

 

 

 

 

 

 

 

 

 

 

 

Protocols

 

Bystander

 

 

 

 

 

Rescue Service

 

 

 

 

 

 

 

 

 

Local Police

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unable to Contact

 

Family

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Law Enforcement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

Other Citizen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sheriff

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Written Orders

 

Patient

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State Patrol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SAFETY EQUIPMENT

 

 

 

 

 

 

 

 

HUMAN FACTORS

 

 

INJURY INTENT

Airbag, Child Safety Seat Used

 

None Used

 

 

 

 

 

 

 

 

Asleep

None

 

Intentional, Self

Airbag Deployed, Lap Belt Used

 

Not Applicable

 

 

 

 

 

 

Physically disabled

 

Intentional, Other

Airbag Deployed, No Lap Belt

 

Personal Flotation Dev.

 

 

 

 

 

 

Physically restrained

 

Unintentional

Airbag, Lap and Shoulder Belt Used

Protective Clothing

 

 

 

 

 

 

Possibly impaired by alcohol

 

Not Applicable

Child Safety Seat

 

Protective Clothing/Gear

 

 

 

 

 

 

Possibly impaired by other drug or chemical

 

Unknown

Eye Protection

 

Shoulder and Lap Belt

 

 

 

 

 

 

Possibly mentally disabled

 

 

 

 

Helmet

 

Shoulder Belt Only

 

 

 

 

 

 

Unattended or unsupervised person

 

 

 

 

Lap Belt Only

 

Unknown

 

 

 

 

 

 

 

 

Unconscious

 

 

 

 

 

SIGNIFICANT EXPOSURE

 

 

 

 

 

 

 

 

 

EXPOSURE PRECAUTIONS

Airborne Exposure

Multiple Exposures

Other Body Fluids

 

All Precautions

Goggles/Gown

 

 

Mask/Goggles/Gown

Blood to Eyes

Needlestick

 

 

 

Saliva to Eyes

 

Gloves

Gown

 

 

None

Blood to Mouth

Not Applicable

 

 

 

Saliva to Mouth

 

Gloves/Mask

Hepafilter

 

 

Not Applicable

Blood to Open Wound

Other

 

 

 

Unknown

 

 

 

 

Gloves/Mask/Gown

Mask

 

 

Other

Mouth to Mouth

 

 

 

 

 

 

 

 

 

 

Goggles

Mask/Goggles

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

 

 

 

 

 

 

(MI)

 

 

 

 

 

Total:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicaid - Title XIX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare/Medicaid

(Address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

(City)

(State)

 

 

 

 

(Zip)

 

(Phone)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not Applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT DISPOSITION

Allowed Treatment, Refused Transport

Canceled by EMS

Canceled by Fire Department Canceled by First Response

Canceled by Law Enforcement

Dead at Scene

No Patient Found

No Treatment Required

Non-Emergency, Alternate Transport

Not Applicable

Refused Treatment, Allowed Transport Refused Treatment, Refused Transport

Treated and Released

Treated, Transferred Care

Treated, Transported by EMS, Improved Treated, Transported by EMS, No Change

Treated, Transported by EMS, Worsened

Treated, Transported by Private Vehicle Unknown

TIME

NARRATIVE

Turned care over to:

 

CREW BOX

Staff ID

Driver

Level

Crew Memb 1:

 

 

Y

N

 

 

 

 

 

 

 

Crew Memb 2:

 

 

Y

N

 

 

 

 

 

 

 

Crew Memb 3:

 

 

Y

N

 

 

 

 

 

 

 

Crew Memb 4:

 

 

Y

N

 

 

 

 

 

 

 

Date:

Signature

Page 3

EKG STRIPS

6

Service Name:

Patient Name:

Run Report Date:

Pageof

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