Prehospital Care Report PDF Details

When emergency medical services (EMS) respond to a call, every detail of their response and the patient care they provide is meticulously recorded in a document known as the Prehospital Care Report form. This form is crucial for several reasons: it ensures continuity of care by providing hospital staff with a comprehensive overview of the patient's condition and treatment prior to arrival, it serves as a legal document that can be used in court if necessary, and it aids in quality control and improvement efforts within the EMS system. The Prehospital Schedule Report covers everything from the initial dispatch information, including the time and nature of the call, to detailed accounts of the treatment provided and the patient's response to that treatment. It also includes demographic information about the patient, the condition codes, medication administered, and procedures performed, making it an invaluable tool for patient care and the ongoing training and development of EMS personnel. Furthermore, this form helps in reviewing incidents and identifying areas where EMS responses can be improved, contributing to the overall effectiveness and efficiency of emergency medical services.

QuestionAnswer
Form NamePrehospital Care Report
Form Length3 pages
Fillable?Yes
Fillable fields1220
Avg. time to fill out34 min 58 sec
Other namespatient care report template, ems patient care report pdf, ems patient care report template, patient care report pdf

Form Preview Example

Prehospital Care Report

1.INCIDENT DATE

-

 

 

-

2.OKLAHOMA REPORT NUMBER

3.EMS AGCY #

4.VEHICLE NUMBER

5.EMS UNIT CALL SIGN

6.STATION #

7.INCIDENT/PATIENT DISPOSITION

Treated, Transport EMS

No Treatment Required

No Patient Found Pt Refused Care

Treated, Transferred Care Treated & Released

Treated, Transported Law Enforcement Treated, Transported Private Vehicle

Canceled Dead at Scene

8. INCIDENT ADDRESS

9. INCIDENT CITY

10. INCIDENT ST 11. INCIDENT ZIP

12. INCIDENT COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. RESPONSE MODE TO SCENE 14. FROM SCENE

 

 

 

 

 

 

 

 

Run Times

 

 

 

 

 

 

 

 

 

 

19.

 

 

 

 

 

 

Unit Arrived at Scene:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lights/Sirens

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Use Military Time

 

 

 

 

 

 

 

 

 

 

20.

 

 

 

 

 

 

 

Arrived at Patient:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No Lights/No Sirens

 

 

 

 

 

 

 

 

 

15.

Estimated Time of Onset:

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

 

 

 

 

 

 

 

 

Unit Left Scene:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial Lights/Sirens Downgraded to no Lights/Sirens

 

 

 

 

 

16.

PSAP / Initial Call for Help:

 

 

 

 

 

 

 

 

 

 

 

 

 

22.

 

Patient Arrived at Destination:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unit Notified by Dispatch:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unit Back in Service:

 

 

 

 

 

 

 

 

 

 

 

 

Initial No Lights/Sirens Upgraded to Lights/Sirens

 

 

 

 

 

17.

 

 

 

 

 

 

 

 

 

 

 

 

 

23.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

 

 

 

 

 

Unit Enroute:

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

 

 

Unit Back at Home Location:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. TYPE OF SERVICE REQUESTED

 

 

 

 

 

26. INCIDENT LOCATION TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

27. CONDITION CODE(S) SEE REFERENCE SHEET

911 Response

Medical Transport

 

 

 

Home/residence

 

 

 

 

 

Farm

 

 

 

 

 

 

 

Mine/quarry

 

 

Industrial place

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Interfacility Transfer

Intercept

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sport/recreation place

 

 

 

Street/highway

 

Public building

 

 

Trade/service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mutual Aid

Standby

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health care facility

 

 

 

 

 

Residential institution

 

Lake/river

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. COMPLAINT REPORTED BY DISPATCH

 

29. EMERGENCY MEDICAL DISPATCH PERFORMED

 

 

 

30. CMS LEVEL OF SERVICE

 

 

 

 

 

 

 

 

 

 

 

(select one) SEE REFERENCE SHEET

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

Yes, with pre-arrival instructions

 

 

 

 

 

BLS, Emergency

 

BLS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes, without pre-arrival instructions

 

 

Unknown

 

 

 

 

 

N/A

 

 

 

 

 

ALS, Level 1 Emergency

 

ALS Lev 1

31. NUMBER OF PATIENTS AT SCENE

 

32. MASS CASUALTY

 

 

 

 

 

33. PRIMARY ROLE OF THE UNIT

 

 

 

 

 

ALS, Level 2

 

Helicopter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transport

 

Supervisor

 

 

 

 

 

Paramedic Intercept

 

 

Airplane

Single

None

Multiple

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty Care

 

Not Applicable

 

 

 

Yes

No

N/A

 

 

 

Non-transport

 

Rescue

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ODOMETER READINGS

 

 

 

 

38. DEST ZIP

 

 

 

 

 

39. ORIG FAC ID

 

 

40. REC FAC ID

 

41. LATITUDE

 

LONGITUDE

34. Begin

 

 

 

 

35. Arrive

 

36. Destination

37. End

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

42. PATIENT LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

43. PATIENT FIRST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

44. M I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

45. PATIENT ADDRESS

46. SAME AS INCIDENT ADDRESS

47.PATIENT CITY

48.

STATE

49.

PATIENT ZIP CODE

 

 

 

 

 

 

50. COUNTY

51. PT TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Area Code

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

55.

AGE

56.

AGE UNITS

 

 

57. DATE OF BIRTH

 

 

 

 

58. SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

Hours

Days

 

 

 

 

-

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Months

Years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

52.RACE (single-choice)

American Indian/Alaska Nat

African American/Black

Asian

Native Hawaiian/Pac Islander

White

Other

53.ETHNICITY

Hispanic

Not Hispanic

54.GENDER

Female

Male

59.PRIMARY PAYMENT METHOD

Not Billed

Unknown

Self Pay

Not Available

Workers Comp

Insurance

Medicare

Medicaid

Other Government

Not Applicable

Medicare #: _______________

Insurance1 #: _____________

Medicaid #: _______________

Insurance2 #: _____________

60.CHIEF COMPLAINT

61.PATIENT MEDICAL HISTORY

62.PATIENT MEDICATION HISTORY

63.PATIENT MEDICATION ALLERGIES

64.NARRATIVE:

Receiving Facility: _________________I received a verbal & written report on the care of this patient: __________________________________________________

INITIAL & FINAL VITAL SIGNS

 

Not Applicable

 

 

 

 

 

 

 

 

 

 

GLASGOW COMASCALE

Not Applicable

 

 

65.

 

66.

 

 

67.

68.

69.

 

70.

 

71.

72.

 

 

73.

 

74.

 

 

75.

 

 

 

76.

 

77.

78.

79.

Time

 

Pulse

 

Resp

SBP

DBP

 

Method BP

LOC

O2 Sat

 

 

EKG

Skin

 

Pupils

 

 

Eyes

Verbal

Motor

GCS Score

 

 

 

 

 

 

 

 

 

Arterial Line

A

 

 

 

 

 

 

Warm

Pale

Left

Right

 

4 Spon

5 Oriented

6 Obeys

 

 

 

 

 

 

 

 

 

 

Auto Cuff

V

 

 

 

 

 

 

Cool

Pink

 

Normal

 

 

3 Speech

4 Confused

5 Localizes

 

 

 

 

 

 

 

 

 

 

Manual Cuff

P

 

 

 

 

 

 

Dry

 

 

Constricted

 

 

2 Pain

3 Inapprop

4 W/draws

 

 

 

 

 

 

 

 

 

 

Palpate Cuff

U

 

 

 

 

SEE

Moist

 

 

Dilated

 

 

1 None

2 Garbled

3 Flexion

 

 

 

 

 

 

 

 

 

 

Venous Line

 

 

 

 

 

REFERENCE

Cyanotic

 

Non-Reactive

 

 

 

 

1 None

2 Extent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SHEET

Diaphoretic

 

 

 

 

 

 

 

1 None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Arterial Line

A

 

 

 

 

 

 

Warm

Pale

Left

Right

 

4 Spon

5 Oriented

6 Obeys

 

 

 

 

 

 

 

 

 

 

Auto Cuff

V

 

 

 

 

 

 

Cool

Pink

 

Normal

 

 

3 Speech

4 Confused

5 Localizes

 

 

 

 

 

 

 

 

 

 

Manual Cuff

P

 

 

 

 

SEE

Dry

 

 

Constricted

 

 

2 Pain

3 Inapprop

4 W/draws

 

 

 

 

 

 

 

 

 

 

Palpate Cuff

U

 

 

 

 

Moist

 

 

Dilated

 

 

1 None

2 Garbled

3 Flexion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Venous Line

 

 

 

 

 

Cyanotic

 

Non-Reactive

 

 

 

 

1 None

2 Extent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SHEET

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diaphoretic

 

 

 

 

 

 

 

1 None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICATIONS

 

None

 

Not applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

80.Time

 

81. Medication Given SEE REFERENCE SHEET

82. Meds Administered By:

 

83. Med Complications SEE REFERENCE SHEET

 

 

84. Medication Authorization

 

:

 

 

 

 

 

 

 

 

 

CM 1

CM 2

CM 3

 

 

 

 

 

 

 

 

Protocol (Standing Order)

On-Line

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Written Orders (Patient Specific)

On-Scene

Not Applicable

:

 

 

 

 

 

 

 

 

 

CM 1

CM 2

CM 3

 

 

 

 

 

 

 

 

Protocol (Standing Order)

On-Line

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Written Orders (Patient Specific)

On-Scene

Not Applicable

:

 

 

 

 

 

 

 

 

 

CM 1

CM 2

CM 3

 

 

 

 

 

 

 

 

Protocol (Standing Order)

On-Line

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Written Orders (Patient Specific)

On-Scene

Not Applicable

PROCEDURES

 

None

 

Not applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

85. Time

 

86. Procedure

SEE RREFERENCE SHEET

87. # Attempts

 

88. Successful

 

89. Done By:

 

 

 

90. Procedure Complications SEE REFERENCE SHEET

:

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

NO

NA

 

CM 1

 

CM 2

CM 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

NO

NA

 

CM 1

 

CM 2

CM 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

NO

NA

 

CM 1

 

CM 2

CM 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I have been given notice of HIPAA Privacy Practices.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is to certify that I am refusing treatment/transport. I have been informed of the risk(s) involved, and thereby release the ambulance service, its attendants, and its affiliates from responsibility that may result from this action.

Patient Authorization & Release: I, the undersigned, hereby authorize __________________________________ (“Provider”) to provide me with emergency or non-emergency

transportation and/or any medical treatment or services it deems necessary. I acknowledge that I am responsible for paying for all charges based on Providers current billing rates, regardless of whether or not I personally requested emergency medical services (EMS) originally. I hereby assign to Provider all my insurance and third party agency benefits for EMS and authorize such benefits to be paid to Provider. I authorize the release of any medical, hospital, or other records or information about me, or my dependents to my insurance carriers in order to determine insurance or other third party benefits for EMS to which my dependents or I may be entitled.

__________________________________________

_______________________________________________________________________

Witness

Date / Time

Patient / Guardian

Date / Time

1

Prehospital Care Report Number:

SYMPTOMS 91. P=PRIMARY (pick one)

Not applicable

 

92. A =ASSOCIATED (multi)

Not applicable

P A

P A

 

 

Transport Only

Fever

 

None

Malaise

 

Bleeding

Mass/Lesion

 

Breathing

Mental/Psych

 

Changes in Responsiveness

Nausea/Vomiting

 

Choking

Pain

 

Death

Palpitations

 

Device/Equip Problem

Rash/Itching

 

Diarrhea

Swelling

 

Drainage/Discharge

Weakness

 

 

Wound

PROVIDER IMPRESSION 93. P= PRIMARY (pick one)

P SP S

Abdominal pain

Airway obstruct

Allergic reaction

Altered LOC

Behavior/psych

Cardiac arrest

Cardiac arrhythmia

Chest pain

CHF COPD

Not applicable

94. S=SECONDARY (pick one)

Not applicable

P

S

 

 

 

 

Diabetic

Respiratory arrest

95. ALCOHOL/DRUG USE

Electrocution

Respiratory distress

INDICATORS (multi-choice)

Hyperthermia

Seizure

 

Not applicable

Hypothermia

Sexual assault/rape

 

 

None

Hypovolemia/shock

Stings/venomous bites

 

 

Smell of alcohol present

Inhalation injury/toxic gas

Stroke/CVA

 

 

Pt admits to alcohol use

Inhalation/smoke

Syncope/fainting

 

 

Pt admits to drug use

Obvious Death

Traumatic injury

 

 

Alcohol and/or drug

Poisoning/drug OD

Vaginal hemorrhage

 

paraphernalia at scene

Pregnancy/OB delivery

 

 

 

 

 

 

 

 

 

96. CHIEF COMPLAINT ANATOMIC LOCATION

Not applicable

 

97. CHIEF COMPLAINT ORGAN SYSTEM

 

 

 

 

 

 

 

 

 

 

 

98. Incident Work-Related

 

Abdomen

 

Extremity Lower

 

 

Genitalia

 

 

 

 

 

Not applicable

Endocrine/Metabolic

Musculoskeletal

 

 

 

Pulmonary

 

 

Yes

 

 

No

 

Back

 

Extremity Upper

 

 

Head

 

 

 

 

 

Cardiovascular

GI

 

 

 

OB/GYN

 

 

 

Renal

 

 

Unknown

 

 

 

Chest

 

General/Global

 

 

Neck

 

 

 

 

 

CNS/Neuro

Global

 

 

 

Psych

 

 

 

Skin

 

 

Not applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

99. CARDIAC ARREST

 

 

 

100. RESUSCITATION (multi)

 

 

101. TIME OF ARREST (mins)

 

102. ARREST

 

 

 

103. CAUSE OF ARREST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applicable

 

 

 

WITNESSED BY:

 

Not applicable

 

Drowning

 

Not applicable

 

 

 

 

 

 

Not applicable

 

 

 

 

 

 

 

 

0-2

 

 

 

 

 

2-4

 

 

 

Not applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

Respiratory

 

Yes, Prior to Arrival

 

 

 

 

 

Defibrillation

 

 

 

None-DOA

 

4-6

 

 

 

 

 

6-8

 

 

 

Lay Person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Presumed Cardiac

 

Electrocution

 

Yes, After Arrival

 

 

 

 

 

 

Ventilation

 

 

 

None-DNR/DNAR

 

8-10

 

 

 

 

 

10-15

 

 

 

Healthcare Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Trauma

 

 

 

Other

 

No

 

 

 

 

 

 

Chest Comp

 

 

 

None-Signs of life

 

15-20

 

 

 

 

>20

 

 

 

Not Witnessed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEMI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applicable

 

108. Stroke Scale

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

104. 12-Lead EKG used:

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

Not applicable

 

 

Not available

 

 

Not known

105.

Transmitted for interpretation:

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

Cincinnati Stroke Scale Negative

 

 

 

 

LA Stroke Scale Negative

106.

Interpreter (indicate all):

 

 

 

Paramedic

 

Physician

Computer Program

 

 

Cincinnati Stroke Scale Non-conclusive

 

 

LA Stroke Scale Non-conclusive

107.

STEMI probable:

 

 

 

 

Yes

 

 

 

No

 

Inconclusive

 

 

Cincinnati Stroke Scale Positive

 

 

 

 

LA Stroke Scale Positive

 

PRIOR AID RECEIVED PRIOR TO ARRIVAL OF UNIT See Reference Sheet

 

 

 

 

 

 

 

111. OUTCOME OF PRIOR AID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

109. PRIOR AID PERFORMED BY:

 

 

110. PRIOR AID (Use PROCEDURES

 

 

Improved

 

 

Unchanged

 

 

Worse

 

 

Unknown

 

 

 

List and/or MEDICATIONS List)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMS Provider

 

Other Health Care Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

112. BARRIERS TO EFFECTIVE CARE [multi-choice]

 

 

 

 

 

Law Enforcement

 

Lay Person

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applicable

 

 

 

 

 

 

 

Physically Impaired

 

 

 

EMS Provider

 

Other Health Care Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Developmentally Impaired

 

 

 

 

Physically Restrained

 

 

 

Law Enforcement

 

Lay Person

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unattended/Unsupervised

 

 

 

 

Speech Impaired

 

 

 

EMS Provider

 

Other Health Care Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hearing Impaired

 

 

 

 

Unconscious

 

 

 

 

 

Law Enforcement

 

Lay Person

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Language

 

 

 

 

 

 

 

None

 

 

 

 

 

EMS Provider

 

Other Health Care Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unattended or unsupervised (including minors)

 

 

 

 

 

 

 

Law Enforcement

 

Lay Person

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

113. TRAUMA

 

114. CAUSE

 

115. MECHANISM OF

 

 

 

116. HOSPITAL TEAM NOTIFIED

 

117. TIME HOSPITAL

 

118. Trauma Triage Level

 

 

 

 

 

PRESENT

 

OF INJURY

 

INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEAM NOTIFIED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applicable

 

 

Priority 2

 

Not applicable

 

 

Not applicable

Not applicable

 

 

 

Not applicable

 

 

 

Trauma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

Yes

 

 

 

 

Stroke

 

 

 

 

 

 

 

 

 

Priority 1

 

 

Priority 3

 

 

 

 

 

 

Blunt

Penetrating

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

No

 

 

 

 

STEMI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Burn

Not Known

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

See Ref. Sheet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

119. TRAUMA TRIAGE CRITERIA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intercept:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

124. TRAUMA REFERRAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CENTER (TreC)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applicable

 

 

 

 

 

Flail chest

 

 

 

 

 

 

 

 

 

 

120.TIME REQUESTED:

 

 

121.TIME ARRIVED:

 

 

NOTIFIED

 

 

 

GCS <=13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Two or more proximal long bone fractures

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GCS improving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

N/A

 

 

 

 

 

 

Open or depressed skull fracture

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resp compromise resulting from trauma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unstable pelvis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

125.TreC

 

 

126. TIME

 

Hemodynamic compromise from trauma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PTS <= 8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blunt trauma/no hemodynamic trauma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRACKING#:

TReC

 

 

BSA >= 10%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Penetrating injury to trunk-neck-head

 

 

 

 

 

 

 

 

 

 

 

122.TIME OF CARE TRANSFER:

 

 

123.REC AGENCY:

 

 

N/A

 

 

NOTIFIED:

 

 

BSA < 10%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Penetrating injuries to extremities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

Other single system injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amputation proximal to wrist or ankle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Minor injuries

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paralysis resulting from trauma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

127. VEHICULAR INJURY INDICATORS

 

 

 

 

Not applicable

 

 

 

 

128. USE OF SAFETY EQUIPMENT [multi]

 

 

Not applicable

 

 

None

 

Dash Deformity

 

 

Fire

 

 

 

 

 

Space Intrusion >1 foot

 

 

 

 

 

Child Restraint

 

 

Lap Belt

 

 

 

 

 

 

 

 

Protective Gear

 

DOA Same Vehicle

 

Rollover/Roof Deformity

Windshield Spider/Star

 

 

 

 

 

Eye Protection

 

 

Pers Flotation Device

 

 

 

Shoulder Belt

 

Ejection

 

 

Side Post Deformity

 

 

Steering Wheel Deformity

 

Helmet Worn

 

 

Protective Clothing

 

 

 

Other (Airbag)

 

129. AIRBAG DEPLOYMENT

 

 

 

 

 

 

 

 

 

Not applicable

 

130. PATIENT POSITION

 

 

Not applicable

 

 

 

 

 

 

Unknown

 

 

 

Airbag Deployed Front

 

Airbag Deployed Other

 

No Airbag Present

 

 

 

Driver

 

 

Left (non-driver)

 

 

Middle

 

 

 

Right

 

Other

 

 

 

Airbag Deployed Side

 

Airbag Not Deployed

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

131. TYPE OF DESTINATION

 

 

 

 

 

 

 

132. REASON FOR CHOOSING DESTINATION

 

133. ED DISPOSITION

 

 

134. HOSPITAL DISPOSITION

 

Home

 

 

 

 

Hospital

 

 

 

 

Closest

 

 

 

 

 

 

On-line Med Control

 

 

 

Admit-floor

 

 

 

 

Death

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Admit-ICU

 

 

 

 

Discharge

 

Not applicable

 

Medical Office/Clinic

 

 

 

Morgue

 

 

 

 

Diversion

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Death

 

 

 

 

Transfer-other hosp

 

 

 

Nursing Home

 

 

 

 

Other EMS (air)

 

 

 

Family Choice

 

 

 

 

 

Pt Choice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not Applicable

 

 

 

 

Transfer-nursing home

 

Other EMS (ground)

 

 

 

Police/Jail

 

 

 

 

Insurance

 

 

 

 

 

 

Pt Physician’s Choice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Released

 

 

 

 

Transfer-other

 

 

 

 

 

Other

 

 

 

 

Not applicable

 

 

 

Law Enforcement Choice

Protocol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transferred

 

 

 

 

Transfer-rehab

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialty Resource Center

Not applicable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

135. TYPE OF DELAY(S)

136. TYPE OF DELAY(S)

 

137. TYPE OF DELAY(S)

 

138. TYPE OF DELAY(S)

 

 

139. TYPE OF DELAY(S) (select all)

 

(select all)

 

 

(select all)

 

 

 

 

SCENE (select all)

 

 

 

 

 

 

TRANSPORT (select all)

 

 

RETURN

 

 

 

 

 

 

 

DISPATCHER

 

 

RESPONSE

 

 

 

 

Not applicable

 

 

 

 

 

 

 

Not applicable

 

 

 

 

 

 

Not applicable

 

 

 

 

 

Not applicable

 

 

 

Not applicable

 

 

 

 

None

 

 

 

 

 

 

 

 

 

None

 

 

 

 

 

 

None

 

 

 

 

 

 

 

None

 

 

 

None

 

 

 

 

 

 

Crowd

 

 

 

 

 

 

 

 

 

Crowd

 

 

 

 

 

 

Clean up

 

 

 

 

 

 

 

Caller Uncooperative

 

 

Crowd

 

 

 

 

 

 

Directions

 

 

 

 

 

 

 

 

Directions

 

 

 

 

 

 

Decontamination

 

 

 

 

 

High Call Volume

 

 

 

Directions

 

 

 

 

 

 

Distance

 

 

 

 

 

 

 

 

Distance

 

 

 

 

 

 

Documentation

 

 

 

 

 

Language Barrier

 

 

 

Distance

 

 

 

 

 

 

Diversion

 

 

 

 

 

 

 

 

Diversion

 

 

 

 

 

 

ED Overcrowding

 

 

 

 

 

Location (Inability to obtain)

 

Diversion

 

 

 

 

 

 

Extrication>20 Min

 

 

 

 

 

 

 

HazMat

 

 

 

 

 

 

Equipment Failure

 

 

 

 

 

No Unit Available

 

 

 

HazMat

 

 

 

 

 

 

HazMat

 

 

 

 

 

 

 

 

Safety Conditions

 

 

 

Equipment Replenishment

 

 

 

Safety Conditions

 

 

 

Safety Conditions

 

 

 

 

Language Barrier

 

 

 

 

 

 

 

Staff Delay

 

 

 

 

 

 

Staff Delay

 

 

 

 

 

 

 

Technical Failure

 

 

 

Staff Delay

 

 

 

 

Safety Conditions

 

 

 

 

 

 

 

Traffic

 

 

 

 

 

 

Vehicle Failure

 

 

 

 

 

Other

 

 

 

Traffic

 

 

 

 

 

 

Staff Delay

 

 

 

 

 

 

 

Vehicle Crash

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle Crash

 

 

 

 

Traffic

 

 

 

 

 

 

 

 

 

Vehicle Failure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle Failure

 

 

 

 

Vehicle Crash

 

 

 

 

 

 

 

Weather

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weather

 

 

 

 

 

 

Vehicle Failure

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

Weather

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter CREW MEMBER Information for:

140. CREW MEMBER ID NUMBER

141. LEVEL OF SERVICE

142. CREW MEMBER ROLE

 

 

 

 

 

 

 

 

 

 

 

 

CREW MEMBER 1 ID NUMBER

 

 

 

 

 

 

 

CREW MEMBER 2 ID NUMBER

 

 

 

 

 

 

 

 

 

CREW MEMBER 3 ID NUMBER

 

 

 

 

____________________________________________________________

 

 

 

____________________________________________________________

 

 

 

____________________________________________________________

 

 

Crew Member1 Signature

 

 

 

 

 

 

 

 

 

 

 

Crew Member2 Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Crew Member3 Signature

 

 

 

 

 

 

 

 

 

 

 

 

Ο B

Ο I Ο P Ο EMR

Ο Physician

 

Ο Nurse Ο Student Ο Other

 

 

Ο B Ο I

Ο P

Ο EMR

Ο Physician Ο Nurse Ο Student Ο Other

 

 

Ο B Ο I Ο P

Ο EMR

 

Ο Physician

Ο Nurse Ο Student Ο Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CREW MEMBER 1 ROLE

 

 

 

 

 

 

 

 

 

CREW MEMBER 2 ROLE

 

 

 

 

 

 

 

 

 

CREW MEMBER 3 ROLE

 

 

 

 

 

 

 

Primary Patient Caregiver

 

 

 

 

Driver

 

 

 

Primary Patient Caregiver

 

 

 

 

Driver

 

 

Primary Patient Caregiver

 

 

 

 

Driver

 

Secondary Patient Caregiver

 

 

 

 

Other

 

 

 

Secondary Patient Caregiver

 

 

 

 

Other

 

 

Secondary Patient Caregiver

 

 

 

 

Other

 

Third Patient Caregiver

 

 

 

 

 

 

 

 

 

 

Third Patient Caregiver

 

 

 

 

 

 

 

 

 

Third Patient Caregiver

 

 

 

 

 

 

Prehospital Care Report

SUPPLEMENTAL PAGE

 

Oklahoma Report Number from 1st page:

 

 

PATIENT LAST NAME from 1st page:

 

 

INCIDENT DATE from 1st page:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional PATIENT MEDICAL HISTORY from 1st page:

Additional PATIENT MEDICATION HISTORY from 1st page:

Additional PATIENT ALLERGIES from 1st page:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional NARRATIVE from 1st page:

Report Given to: _____________________________________; Narrative page ___ of ___ pages

Necessity For Service

 

 

 

Patient moved to

Was patient

Did patient require

Patient placed in

Upon arrival, Patient

Was stretcher necessary?

 

Stretcher via

Incontinent

IV

Ambulating

Found in:

Unable to sit upright

MI

Total lift

Combative

Saline hep lock

Geri Cardiac Chair

Ambulating

Unable to balance in sitting position

Unset or poss fracture

Draw sheet

Confused/lethargic

Drug therapy

Recliner

Geri Cardiac Chair

Unconscious/shock

Acute stroke

Other _________

Dizzy

Oxygen

Wheelchair

Recliner

Req. physical restraints

MVC

Did patient

Weak

Intubation

Bed

Wheelchair

Severe hemorrhage

Other _________

Vomit

Other _______

Ventilator

Gurn/exam table

Bed

Bed Confined

 

 

Complain of nausea

 

EKG monitor

Other _____

Gurney/exam table

Fetal position

Contractures

Paralyzed

Complain of pain

 

Chemstrip

 

Floor

 

 

 

 

 

Other ______

 

Other _________

 

 

 

 

 

 

 

 

Additional VITAL SIGNS & Glasgow Coma Scale from 1st page:

Glasgow Coma Scale

 

 

 

 

Pediatric Trauma Score:

Age 12 and under

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O2

 

 

 

 

 

 

 

 

 

 

 

 

 

GCS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time Pulse

 

Resp

SBP DBP

Method BP

LOC

Sat

 

 

EKG

Eyes

 

 

Verbal

 

Motor

 

Score

Weight

Airway

CNS

BP

Wounds

Skeletal 143. PT Score

 

 

 

 

 

 

 

Arterial Line

 

A

 

 

 

 

 

4 Spon

 

5 Oriented

 

6 Obeys

 

 

 

 

Initial:

 

Initial:

 

Initial:

 

Initial:

 

Initial:

 

Initial:

 

Initial:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Auto Cuff

 

V

 

 

 

 

 

3 Speech

 

4 Confuse

 

5 Localizes

 

 

 

>20:+2

 

Normal:+2

 

Awake:+2

 

>90:+2

 

 

 

None: +2

 

 

None:+2

 

 

 

 

 

 

 

 

 

 

 

Manual Cuff

 

 

 

 

 

 

2 Pain

 

3 Inapprop

 

4 W/draws

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

 

 

 

 

 

10-20: 1

 

Maint:+1

 

Obtund:+1

 

90-50: 1

 

 

Minor: 1

 

 

Closed fx:+1

 

_____

 

 

 

 

 

 

 

 

Palpate Cuff

 

 

 

 

See Ref

1 None

 

2 Garbled

 

3 Flexion

 

 

 

 

<10:-1

 

Unmaint:-1

 

Coma:-1

 

<50:-1

 

 

 

Major:-1

 

 

Open:-1

 

 

 

 

 

 

 

 

 

 

U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Venous Line

 

 

 

 

Sheet

 

 

 

1 None

 

2 Extent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6 Obeys

 

 

 

 

Final:

 

Final:

 

Final:

 

Final:

 

Final:

 

Final:

 

 

 

 

 

 

 

 

 

 

 

Arterial Line

 

A

 

 

 

 

 

4 Spon

 

5 Oriented

 

5 Localizes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Auto Cuff

 

 

 

 

 

 

3 Speech

 

4 Confuse

 

4 W/draws

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

 

 

 

 

 

 

>20:+2

 

Normal:+2

 

Awake:+2

 

>90:+2

 

 

 

None: +2

 

 

None:+2

 

 

 

 

 

 

 

 

 

 

 

Manual Cuff

 

 

 

 

 

 

2 Pain

 

3 Inapprop

 

3 Flexion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

 

 

 

 

 

 

10-20: 1

 

Maint:+1

 

Obtund:+1

 

90-50: 1

 

 

Minor: 1

 

 

Closed fx:+1

 

 

 

 

 

 

 

 

 

 

 

Palpate Cuff

 

 

 

 

See Ref

1 None

 

2 Garbled

 

2 Extent

 

 

 

 

<10:-1

 

Unmaint:-1

 

Coma:-1

 

<50:-1

 

 

 

Major:-1

 

 

Open:-1

 

 

 

 

 

 

 

 

 

 

 

 

U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Venous Line

 

 

 

 

Sheet

 

 

 

1 None

 

1 None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6 Obeys

 

 

 

 

>20:+2

 

Normal:+2

 

Awake:+2

 

>90:+2

 

 

 

None: +2

 

 

None:+2

 

 

 

 

 

 

 

 

 

 

 

Arterial Line

 

A

 

 

 

 

 

4 Spon

 

5 Oriented

 

5 Localizes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10-20: 1

 

Maint:+1

 

Obtund:+1

 

90-50: 1

 

 

Minor: 1

 

 

Closed fx:+1

 

 

 

 

 

 

 

 

 

 

 

Auto Cuff

 

 

 

 

 

 

3 Speech

 

4 Confuse

 

4 W/draws

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

 

 

 

 

 

 

<10:-1

 

Unmaint:-1

 

Coma:-1

 

<50:-1

 

 

 

Major:-1

 

 

Open:-1

 

 

 

 

 

 

 

 

 

 

 

Manual Cuff

 

 

 

 

 

 

2 Pain

 

3 Inapprop

 

3 Flexion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Palpate Cuff

 

 

 

 

See Ref

1 None

 

2 Garbled

 

2 Extent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Venous Line

 

 

 

 

Sheet

 

 

 

1 None

 

1 None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6 Obeys

 

 

 

 

>20:+2

 

Normal:+2

 

Awake:+2

 

>90:+2

 

 

 

None: +2

 

 

None:+2

 

 

 

 

 

 

 

 

 

 

 

Arterial Line

 

A

 

 

 

 

 

4 Spon

 

5 Oriented

 

5 Localizes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10-20: 1

 

Maint:+1

 

Obtund:+1

 

90-50: 1

 

 

Minor: 1

 

 

Closed fx:+1

 

Final:

 

 

 

 

 

 

 

Auto Cuff

 

 

 

 

 

 

3 Speech

 

4 Confuse

 

4 W/draws

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V

 

 

 

 

 

 

 

 

 

 

<10:-1

 

Unmaint:-1

 

Coma:-1

 

<50:-1

 

 

 

Major:-1

 

 

Open:-1

 

 

 

 

 

 

 

 

 

 

 

Manual Cuff

 

 

 

 

 

 

2 Pain

 

3 Inapprop

 

3 Flexion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Palpate Cuff

 

 

 

 

See Ref

1 None

 

2 Garbled

 

2 Extent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____

 

 

 

 

 

 

 

 

 

U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Venous Line

 

 

 

 

Sheet

 

 

 

1 None

 

1 None

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICATIONS

Continued from 1st page

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

 

Medication Given See Reference Sheet

 

 

Medication Administered By:

 

Reactions

See Reference Sheet

 

Medication Authorization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Protocol (Standing Order)

 

 

On-Line

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CM 1

CM 2

CM 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Written Orders (Patient Specific)

On-Scene

Not applic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Protocol (Standing Order)

 

 

On-Line

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CM 1

CM 2

CM 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Written Orders (Patient Specific)

On-Scene

Not applic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Protocol (Standing Order)

 

 

On-Line

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CM 1

CM 2

CM 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Written Orders (Patient Specific)

On-Scene

Not applic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Protocol (Standing Order)

 

 

On-Line

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CM 1

CM 2

CM 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Written Orders (Patient Specific)

On-Scene

Not applic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Protocol (Standing Order)

 

 

On-Line

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CM 1

CM 2

CM 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Written Orders (Patient Specific)

On-Scene

Not applic

 

PROCEDURES Continued from 1st page

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time

 

Procedure

 

 

 

 

 

 

 

# Attempts

 

Successful

 

 

 

Done By:

 

 

 

Complications

 

 

See Reference. Sheet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

NA

 

 

 

CM 1

CM 2

 

CM3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

NA

 

 

 

CM 1

CM 2

 

CM3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

NA

 

 

 

CM 1

CM 2

 

CM3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

NA

 

 

 

CM 1

CM 2

 

CM3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

NA

 

 

 

CM 1

CM 2

 

CM3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CREW MEMBER 4 ID NUMBER

 

 

 

CREW MEMBER 5 ID NUMBER

 

 

 

 

 

CREW MEMBER 6 ID NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____________________________________________

 

 

____________________________________________

 

 

 

 

_____________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Crew Member4 Signature

 

 

 

 

 

 

Crew Member5 Signature

 

 

 

 

 

 

 

Crew Member6 Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ο B Ο I Ο P

Ο EMR Ο Physician Ο Nurse O Student O Other

 

Ο B

Ο I Ο P Ο EMR Ο Physician Ο Nurse O Student O Other

 

Ο B

Ο I

Ο P Ο EMR Ο Physician Ο Nurse O Student O Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CREW MEMBER 4 ROLE

 

 

 

 

CREW MEMBER 5 ROLE

 

 

 

 

 

 

 

CREW MEMBER 6 ROLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Patient Caregiver

Driver

 

 

Primary Patient Caregiver

 

 

Driver

 

 

 

 

Primary Patient Caregiver

 

Driver

 

 

 

 

 

 

 

 

 

 

 

 

 

Secondary Patient Caregiver

Other

 

 

Secondary Patient Caregiver

Other

 

 

 

 

Secondary Patient Caregiver

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Third Patient Caregiver

 

 

 

 

 

Third Patient Caregiver

 

 

 

 

 

 

 

 

 

 

Third Patient Caregiver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How to Edit Prehospital Care Report Online for Free

We've applied the efforts of the best programmers to create the PDF editor you may want to take advantage of. The app will permit you to fill out the ems patient care report pdf file effortlessly and don’t waste valuable time. All you should undertake is follow these straightforward instructions.

Step 1: Select the button "Get Form Here".

Step 2: Once you've entered the ems patient care report pdf editing page you'll be able to notice all the options you may conduct with regards to your template within the upper menu.

These particular parts are in the PDF file you'll be completing.

portion of empty spaces in pre hospital care report form medical

In the NUMBER, OF, PATIENTS, AT, SCENE Single, None, Multiple, MASS, CASUALTY Yes, PRIMARY, ROLE, OF, THE, UNIT Transport, Non, transport Supervisor, Rescue ODOMETER, READINGS DE, ST, ZIP ORIG, F, ACID RE, CF, ACID Begin, PATIENT, LASTNAME and Arrive box, note down your data.

Filling out pre hospital care report form medical stage 2

Make sure you emphasize the vital data from the PATIENT, MEDICATION, HISTORY PATIENT, MEDICATION, ALLERGIES Receiving, Facility Not, Applicable, GLASGOW, COMA, SCALE INITIAL, FINAL, VITAL, SIGNS, TimeD, BP Pulse, Resp, SBP, Method, BP LOC, OS, at None, Not, applicable A, VP, U and A, VP, U area.

part 3 to entering details in pre hospital care report form medical

Within the part Medication, Given, See, Reference, Sheet Medication, Authorization Meds, Administered, By Med, Complications, See, Reference, Sheet Attempts, Successful, Done, By YES, YES, YES, Not, Applicable Not, Applicable Not, Applicable MEDICATIONS, Time, PROCEDURES, Time and None, place the rights and responsibilities of the sides.

pre hospital care report form medical MedicationGivenSeeReferenceSheet, MedicationAuthorization, MedsAdministeredBy, MedComplicationsSeeReferenceSheet, Attempts, Successful, DoneBy, YES, YES, YES, NotApplicable, NotApplicable, NotApplicable, MEDICATIONSTimePROCEDURESTime, and None fields to complete

Finish the form by looking at the next sections: Pre, hospital, Care, Report, Number Not, applicable, Not, applicable PROVIDER, IMPRESSION, P, PRIMARY, pick, one Not, applicable S, SECONDARY, pick, one Not, applicable ALCOHOL, DRUG, USE, INDICATORS, multi, choice paraphernalia, at, scene CHIEF, COMPLAINT, ANATOMIC, LOCATION Abdomen, Back, Chest Not, applicable, Genitalia, Head, Neck CHIEF, COMPLAINT, ORGAN, SYSTEM Incident, Work, Related Not, applicable, Cardiovascular, CNS, Neuro and Endocrine, Metabolic, GI, Global

Filling out pre hospital care report form medical step 5

Step 3: Choose the "Done" button. Then, you can transfer your PDF file - save it to your device or forward it by means of electronic mail.

Step 4: Ensure that you stay away from future problems by getting as much as a couple of copies of the form.

Watch Prehospital Care Report Video Instruction

Please rate Prehospital Care Report

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .