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wustl_pcr

wustl_pcr

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Published by dandude505

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Categories:Types, Brochures
Published by: dandude505 on Apr 27, 2009
Copyright:Attribution Non-commercial

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05/11/2014

 
EST*
Washington
University
Emergency
Support Team
F'
Grad
Name:SSN:
Address:Phone:
Location:
ChiefCom
Time:
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~
 
:
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iiiii
:
i
Allerg es:Meds:
PastMed
HD AsthmaD Cardiacx:RTo:By:D OtD HIPAAher
DOB:
/
//
/
I
School:
LA
ENAR
FA
BA
Sex: D MaleD Female
Call
#
/D StudentD Guest
Date:
/
/
D Faculty D Other
Dispatch
Time:
D Staff
Arrival
Time:
Clear
Time:
Transfer
Time:
Temp:
D CyanoticD FlushedD JaundicedD UnremarkableD CyanoticD FlushedD JaundicedD UnremarkableD CyanoticD FlushedD JaundicedD Unremarkable
DNo
Stop:
DYes
DNo
DYes
DNo
laintlMechanism:
BP:
D
Taken
NormallyD DiabetesD None
r
\
'I
I'
)
J
::
\
~
 
D PoliceD Ambulance
Pulse:
Rate:
__
Quality:_
D
Regular
D IrregularRate:
__
Quality:_
D
Regular
D IrregularRate:
-
Quality:_
D
Regular
D IrregularD SeizuresD Other
FRONTBACK
LLR
(
...
; ~
1 ~ ~
\
j<,
I
 
II
Attending
Physician
(935-6667)
Contacted?
DYes
DNo
Equipment
Used:
Resps:
Rate:
__
SpOz:
__
%D RegularD
Shallow
D
Labored
Rate:
__
SpOz:
__
%D
Regular
D
Shallow
D
Labored
Rate:
__
SpOz:
__
%D
Regular
D ShallowD
Labored
Cervical SpineTime
C-spine Held:Released
at:
LOC DNo
Head Pain
DNo
Neck Pain
DNo
Back
Pain
DNo
Nausea
DNo
Dizziness
DNo
Blurred
Vision
DNo
Numbness
DNo
Tingling
DNo
Fluid in Ears
DNo
L
Pupils:
RD Normal DDDilatedDD Constricted DD SluggishDD No-Reaction DD NormalDDDilated DDConstrictedDD SluggishDDNo-Reaction DD Normal DD Dilated DD Constricted DD SluggishDD No-Reaction D
DYesDYesDYesDYesDYesDYesDYes
DYes
DYesDYesPeds
D Equal
DWeak
D Unequal
Grips
D
Equal
DWeak
D
Unequal
Notes:Disposition:D Released to SelfD Released to OtherD Transferred CareD Refused TreatmentD Refused TransportD Gone on ArrivalD Disregarded
Medic
1:EMT:
Medic
2:
o
CPRISFA
DEMT:
Medic
3::
EMT:
Police:
Skin:
D CoolD Pale
DWarm
D MoistD
Dry
D OtherD Cool D Pale
DWarm
D MoistD DryD Other
DCool
D Pale
DWarm
D MoistD DryD Other
ETOH
DYes
Source:Quantity:Type:Start:Usual AmountUsual
Rxn
Other
Substance:Injury:Location:Time
of
Injury:PMS:Range
of
Motion:Radiation:Severity:

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