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Patient Care Report

SERVICE NAME:

(PLEASE PRINT)

Service #:

Unit #:

Date of Onset:

Incident #:
Date Unit Notified:

Pt. Record #:

Crash #:

Run Report Date:

Trauma ID #:

Dispatched For:

TIMES (MILITARY)

PATIENT INFORMATION

Dispatch
Notified:

Time Left
Scene:

(Last Name)

Unit Notified:

Arrived at Destination:

(Street Address)

Unit Enroute:

Back In Service:

(City)

Arrived at Scene:

Total Incident Time:

(Phone)

YES
NO

911

Minutes For Response:

Time of Injury/Illness:

(First)

(Apt. #)

(State)

(Gender)

F2

M1
Race

0 Other

Minutes For Transport:

(Age yrs. mons)

(SSN#)

Unk 3

3 American Indian, Eskimo or Aleut

1 White

4 Asian

1 Hispanic

Chief Complaint:
Past Medical History:

Pertinent Findings on Physical Exam:

Allergies:

Patient Medications:

Emerg. Med. Care Given:

Patient Response to Emerg. Med. Care:

0 Other, including multi racial

2 Black
Injury/Illness Narrative:

Provider Impression:

(Zip Code)

(Date of Birth)

Ethnicity

Minutes At Scene:

(MI)

U Undetermined

Select one

Abdominal Pain/Problems

Cardiac Rhythm Disturbance

Hypothermia (Trauma)

Pregnancy/OB Delivery

Stings/Venomous Bites

Airway Obstruction

Chest Pain/Discomfort

Hypovolemia

Psychiatric Disorder

Stroke/CVA

Alleged Sexual Assault

Diabetic Symptoms

Inhalation Injury (Toxic Gas)

Respiratory Arrest

Syncope/Fainting

Allergic Reaction

Electrocution

Not Applicable

Respiratory Distress

Traumatic Hypovolemia

Altered Level of Consciousness

Hyperthermia

Obvious Death

Seizure

Traumatic Injury

Behavioral Disorder

Hypoglycemia

Other

Shock

Vaginal Hemorrhage

Cardiac Arrest

Hypothermia (Disease)

Poisoning/Drug Ingestion

Smoke Inhalation

Unknown

Mutual Aid

EMS Tier

MODE OF TRANSPORT

Destination / Transferred To
Fixed Wing

DESTINATION DETERMINATION/OUT OF HOSPITAL TRIAGE CRITERIA

Closest Facility
Diversion
Family Choice
Law Enforcement Choice

Managed Care
Not Applicable
On-LIne Medical Direction

Other
Patient Choice
Patient Physician Choice

Other

None

Ground

Rotor Craft

Trauma Triage (GCS, Vitals)

Trauma Triage (Mechanism of Injury)
Trauma Triage (Risk Factors)
Unknown

Protocol
Specialty Resource Center
Trauma Triage (Anatomy of Injury)

CLINICAL INFORMATION
Time

B/P

PULSE

RESP

TEMP

Glasgow Coma Scale

Eye Verb Motor Total

Pulse
O2

Revised Trauma Score

(RTS)
BP
GCS Total

Resp

Revised Trauma Score

Pediatric
BP
GCS Total

Resp

Respiratory Effort
1
2
3
4
5
6
7

Resp. Sounds

Normal
N Not Assessed
Shallow/Labored
U Unknown
Shallow/Non-Labored
Deep/Labored
Deep/Non-Labored
Absent
Labored/Fatigued

Skin Perfusion:

Clear
Bronchi
L Rhales
L Wheezes

R
R

Pupils:

R
Normal
Constricted R
R
L
Dilated
L
3 Not Assessed
No react. R
Revised Trauma Score (RTS) Values
Resp. Rate
Systolic B.P.
GCS Total
13-15 4
BP>89 4
10-29 4
9-12
3
76-89 3
>29
3
6-8
2
50-75 2
6-9
2
4-5
1
1-49
1
1-5
1
<4
0
None 0
None 0
L

1 Normal

2 Decreased

For patients 2-5 years:

1 None
2 Grunts
3 Cries and/or screams
4 Inappropriate words
5 Appropriate words
9 Not assessed

For patients 0-23 months:

1 None
2 Persistent cry, grunting
3 Inappropriate cry
4 Cries, inconsolable
5 Smiles, coos, cries
appropriately
9 Not assessed

For patients >5

Motor Component
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

Cardiac Arrest Information

Cardiac Arrest:
Witnessed Arrest:
Trauma Arrest:

Bystander CPR:
Pulse Restored:
Number of Shocks:

Signature

FLIP OVER TO BEGIN PAGE 2

<8

<12

>12

Unk.

TIME COLUMNS)
I D
Time rhythm observed

Date:

PVCs
Sinus Bradycardia
Sinus Rhythm
Sinus Tachycardia

PEA (EMD)
Idioventricular
Junctional
Pacemaker

- 1st
-2nd, Type I
-2nd, Type II
- 3rd

Block
Block
Block
Block

AV
AV
AV
AV

<4

Min.
Arrest to CPR:
Arrest to DEFIB.
Arrest to Meds.

Cardio Pulmonary
Arrest Time:

Not Applicable
Unable to Identify
Asystole
Atrial Fibrillation

Page 1

D = Destination
PLEASE NOTE: ANY CHANGES IN CARDIAC RHYTHM SHOULD BE NOTED BELOW BY (
I D
I D
I D
Time rhythm observed
Time rhythm observed
Time rhythm observed

Cardiac Rhythm: I = Initial

I D
Time rhythm observed

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
6 Spontaneous
9 Not assessed

0
1
2
3
4

Verbal Component
For patients >5 years:
1 None
Not applicable
2 Non-specific sounds
None
3 Inappropriate words
Responds to Pain
4 Confused conversation or
Responds to Speech
speech
Spontaneous Opening
5 Oriented and appropriate
speech
9 Unknown

Glasgow Coma Scale (GCS) Values

Eye Opening
Component

ST Elevation/Abnormal
SVT
Vent. Fibrillation
Vent. Tachycardia
Other

34

SERVICE NAME:

(PLEASE PRINT)

Service #:

Unit #:

Incident #:

Date of Onset:

Date Unit Notified:

Pt. Record #:

Crash #:

Run Report Date:

Trauma ID #:

INJURY
Tissue Swelling

Puncture/Stab

Pain

Laceration

Gunshot Wound

Dislocation/Fracture

Crushing Injury

Burn

Blunt Injury

Amputation

Abrasion

INJURY
MATRIX
Select one

Cause of Injury
Accidental Chemical Poisoning
Accidental Drug Poisoning
Accidental Falls
Aircraft Related Accident
Alleged Sexual Assault
Bicycle
Bicycle Accident
Bites
Child Battering
Drowning
Electrocution (Non-lightning)
Excessive Cold
Excessive Heat
Fire and Flames
Firearm Assault
Firearm Injury (Accidental)
Firearm Self-inflicted (Intentional)
Lightning
Machinery Accidents

Head
Face
Neck
Chest
Back
Abdomen
Pelvic / Genitalia
Upper Extremity
Lower Extremity

PROCEDURES
Time

# of Attempts
Assisted Ventilation (Positive Pressure)

Time

Staff ID Staff ID S/U

S = Successful

# of Attempts

Select one
Motor Vehicle Non-traffic Crash
Mechanical Suffocation
Vehicle
Motorcycle
Motorcycle/Vehicle
Not Applicable
Radiation Exposure
Smoke Inhalation
Snowmobile
Stabbing Assault
Vehicle/Bicycle
Vehicle/Fixed Object
Vehicle/Pedestrian
Vehicle/Train
Vehicle/Vehicle
Venomous stings (plants, animals)
Water transport accident
Unknown

U = Unsuccessful

Time

Staff ID Staff ID S/U

# of Attempts

Staff ID Staff ID S/U

Needle Thoracotomy

External Cardiac Pacing

Bleeding Controlled

External Defibrillation (includes auto)

Obstetrical Care (Delivery)

Burn Care

Glucometer

Oropharyngeal Airway Insertion

Cardiopulmonary Resuscitation

Intraosseous Catheter

Other

Cervical Immobilization

Intravenous Catheter

Oxygen by Cannula

Combination Airway/EOA

Intravenous Fluids

Oxygen by Mask

Combination Airway/ET

Long Spineboard

Pulse/Oximeter

Cricothyrotomy

MAST (PASG)

Short Spine Board (KED)

ECG Monitoring

Monitoring a Medicated IV

Suction

Endotracheal Intubation

Nasogastric Tube Insertion

Splint of Extremity

Esophageal Airway

Nasopharyngeal Airway Insertion

Traction Splint

MEDICATIONS
Medication:

Time:

Dosage:

Route:

Comments/
Response:

Staff ID:

SCENE INFORMATION
Scene Address:

Apt. #:

Scene City:

Scene State:

Doctors Office/Clinic
Hospital
Nursing Home
Other Medical Facility
Residences

Road/Highway Areas

Factors Affecting EMS:

Construction Site

Government Building

Adverse Road Conditions

Gravel Road

Farm

Other Public Place

Adverse Weather

Highway (County)

Manufacturing Facility

Recreation Area

Crowd Control

Highway (State)

Office Building

Shopping Center

Hazardous Material

Interstate (55 mph)

Other Job Site

Educational Institutions

Language Barrier

College/University

None

Interstate (65 mph)

Water/Waterways

Other Roadway

Lake/Pond

Grade School

Not Applicable

Street

Other Water Area

High School

Other

Quarry/Pit

Jr. High/Middle School

Prolonged Extrication (>20 min)

River/Stream

Other School

Unsafe Scene

Swimming Pool

Preschool/Daycare

Vehicle Problems

To
Scene

From
Scene

To
Scene

From
Scene

To
Scene

Non emergent, No Lights or Siren

Emergent, with Lights or Siren

Initial non-emergent, upgraded

to Lights or Siren

Page 2

Public Places

Job/Construction Site

Scene Township:

Freeway

City Residence
Farm Residence
Other Residence

Lights
&
Siren:

Scene County:

FLIP OVER TO BEGIN PAGE 3

From
Scene

Initial emergent, downgraded to no Lights or Siren

Not Applicable

Location Type:
Not Applicable
Other
Unknown
Medical Facilities

Scene Zip:

SERVICE NAME:

(PLEASE PRINT)

Service #:

Unit #:

Date of Onset:

Incident #:

Pt. Record #:

Date Unit Notified:

Crash #:

Run Report Date:

PRIOR AID

TREATMENT AUTHORIZATION

EMS Agency/Fire Dept

Trauma ID #:

Health Care Professional

Medical Facility

None

None

Not Applicable

Not Applicable

Ambulance Service

EMT

Doctors Office/Clinic

On-Line Designee

Other

First Responder Service

First Responder

Hospital

On-Line Physician

Unknown

Fixed Wing Service

Other Medical Professional

Helicopter Service

Physician

Nursing Home
Other Medical Facility

Other Agency/Fire Dept

RN/LPN

Other

Citizen/Bystander

Physician at Scene

Bystander

Protocols
Unable to Contact

Family

Unknown

Other Citizen

Written Orders

Patient

Local Police
Other Law Enforcement
Sheriff
State Patrol

SAFETY EQUIPMENT

HUMAN FACTORS
None

Airbag, Child Safety Seat Used

None Used

Asleep

Airbag Deployed, Lap Belt Used

Not Applicable
Personal Flotation Dev.

Physically disabled

Airbag Deployed, No Lap Belt

Airbag, Lap and Shoulder Belt Used

Physically restrained
Possibly impaired by alcohol
Possibly impaired by other drug or chemical
Possibly mentally disabled
Unattended or unsupervised person
Unconscious

Protective Clothing
Protective Clothing/Gear
Shoulder and Lap Belt
Shoulder Belt Only
Unknown

Child Safety Seat

Eye Protection
Helmet
Lap Belt Only

SIGNIFICANT EXPOSURE
Airborne Exposure
Blood to Eyes
Blood to Mouth
Blood to Open Wound
Mouth to Mouth

Law Enforcement

Rescue Service

Multiple Exposures
Needlestick
Not Applicable
Other

Number:

Intentional, Self
Intentional, Other
Unintentional
Not Applicable
Unknown

EXPOSURE PRECAUTIONS
Other Body Fluids
Saliva to Eyes
Saliva to Mouth
Unknown

All Precautions
Gloves
Gloves/Mask
Gloves/Mask/Gown
Goggles

Goggles/Gown
Gown
Hepafilter
Mask
Mask/Goggles

BILLING INFORMATION
Insurance - Primary:

INJURY INTENT

Mask/Goggles/Gown
None
Not Applicable
Other
Unknown

MILEAGE

Insurance - Secondary:

Number:

INSURANCE TYPE

Beg:

No Insurance
Private Pay

End:

Responsible Party:
(Last Name)

(First)

(MI)

Private Insurance
Medicare

Total:

Medicaid - Title XIX

Medicare/Medicaid

(Address)

VA Insurance

(City)

(State)

(Zip)

Unknown

(Phone)

Not Applicable

PATIENT DISPOSITION
Allowed Treatment, Refused Transport

Canceled by Law Enforcement

Non-Emergency, Alternate Transport

Treated and Released

Treated, Transported by EMS, Worsened

Canceled by EMS

Dead at Scene

Not Applicable

Treated, Transferred Care

Treated, Transported by Private Vehicle

Canceled by Fire Department

No Patient Found

Refused Treatment, Allowed Transport

Treated, Transported by EMS, Improved

Unknown

Canceled by First Response

No Treatment Required

Refused Treatment, Refused Transport

Treated, Transported by EMS, No Change

TIME

NARRATIVE

Turned care over to:

CREW BOX

Staff ID

Driver

Crew Memb 1:

Crew Memb 2:

Crew Memb 3:

Crew Memb 4:

Date:

Page 3

Signature

Level

EKG STRIPS

Service Name:

Run Report Date:

Patient Name:

Page

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