Report Patient Care Chart Form – Fill Out and Use This PDF

INCIDENT NUMBER

UNIT ID

INCIDENT DATE

INCIDENT ADDRESS

INCIDENT CITY

INCIDENT STATE

INCIDENT ZIP CODE

INCIDENT COUNTY

INCIDENT LOCATION TYPE SEE REF. SHEET

COMPLAINT REPORTED BY DISPATCH SEE REF. SHEET

PRIMARY PAYMENT

EMERGENCY MEDICAL DISPATCH PERFORMED

LEVEL OF SERVICE

SEE REF. SHEET

No

Yes w/pre-arrival instructions

BLS, Emergency

Yes w/out pre-arrival instructions

ALS, Level 1 Emergency

INCIDENT/PATIENT DISPOSITION

ALS, Level 2

Treated, Transport EMS

No Patient Found

Treated, Transferred care

Treated, Transported Law Enforcement

Specialty Care Transport

Cancelled

No Treatment Required

Pt Refused Care

Helicopter

Treated

& Released

Dead at Scene

Treated, Transported Private Vehicle

Not Applicable

NUMBER OF PATIENTS ON SCENE

MASS CASUALTY

TYPE OF SERVICE REQUESTED

PRIMARY ROLE OF THE UNIT

Single

None

Yes

Scene Response

ED to ED Transfer

Transport

Non-transport

Multiple

No

Mutual Aid

Intercept

Supervisor

Rescue

TYPE OF DELAY (S)

DISPATCHER

RESPONSE

SCENE

TRANSPORT

RETURN

None-N/A

None-N/A

None-N/A

None-N/A

None-N/A

Not known

Crowd

Crowd

Crowd

Clean up

Caller Uncooperative

Directions

Directions

Directions

Decontamination

High Call Volume

Distance

Distance

Distance

Documentation

Language Barrier

Diversion

Diversion

Diversion

ED Overcrowding

Location (Inability to obtain)

Hazmat

Extrication>20 Min

Hazmat

Equipment Failure

No Unit Available

Safety Conditions

Hazmat

Safety Conditions

Equipment Replenishment

Safety Conditions

Staff Delay

Language Barrier

Staff Delay

Other

Technical Failure

Traffic

Safety Conditions

Traffic

Staff Delay

Other

Ambulance Crash

Staff Delay

Ambulance Crash

Ambulance Failure

Ambulance Failure

Traffic

Ambulance Failure

Weather

Ambulance Crash

Weather

Other

Ambulance Failure

Other

Weather

Other

PATIENT LAST NAME

PATIENT FIRST NAME

MI

PATIENT ADDRESS

SAME AS INCIDENT

PATIENT CITY

PATIENT STATE

PATIENT ZIP CODE

AGE

DATE OF BIRTH

GENDER

RACE

ETHNICITY

Female

Male

CURRENT MEDICATIONS

ALLERGIES

PERTINENT HISTORY

INJURY PRESENT

CAUSE OF INJURY SEE REF. SHEET

TYPE OF INJURY

ALCOHOL/DRUG USE INDICATORS

Yes

Blunt

Penetrating

None

Pt admits to drug use

No

Burn

Not Known

Smell of alcohol on breath

Pt admits to alcohol use

Alcohol and/or drug paraphernalia at scene

CHIEF COMPLAINT

CONDITION CODE SEE REF. SHEET

CHIEF COMPLAINT ANATOMIC LOCATION

CHIEF COMPLAINT ORGAN SYSTEM

Abdomen

Extremity Lower

General/Global

CNS/Neuro

OB/GYN

Pulmonary

Endocrine/Metabolic

Chest

Back

Extremity Upper

Global

Renal

Cardiovascular

Gastrointestinal

Head

Neck

Genitalia

Psych

Skin

Musculoskeletal

CARDIAC ARREST

RESUSCITATION

CAUSE OF CARDIAC ARREST

Yes, Prior to Arrival

Defibrillation

None-DOA

Presumed Cardiac

Respiratory

Yes, After Arrival

Ventilation

None-DNR

Trauma

Electrocution

No

Chest Compressions

None-Signs of life

Drowning

Other

USE OF SAFETY EQUIPMENT

AIRBAG DEPLOYMENT

N/A

Lap Belt

Shoulder Belt

Protective Clothing

None Present

Deployed Front

Not Known

Helmet Worn

Protective Non-Clothing Gear

Other

Not Deployed

Deployed Side

Child Restraint

Eye Protection

Personal Floatation Device

None

Deployed Other

N/A

BARRIERS TO STANDARD PATIENT CARE

Development Impaired

Physically Impaired

Unattended/Unsupervised

Hearing Impaired

Physical Restraint

Unconscious

Language

Speech Impaired

RESPONSE MODE

TRANSPORT MODE

Initial Call for Help

:

Unit Left Scene

:

Lights/Sirens

Unit Notified

:

Patient arrived at Destination

:

No Lights/No Sirens

Unit En Route

:

Incident Completed

:

Initial Lights/Sirens Downgraded to no Lights/Sirens

Arrive on Scene

:

Available for Next Incident

:

Initial No Lights/Sirens Upgraded to Lights/Sirens

Arrived at PT.

:

PRIOR AID SEE REF. SHEET

PRIOR AID OUTCOME Improved

Unchanged

Worse

Unknown