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INDONESIAN FIRE & RESCUE

Injury/Illness/Treatment Form

Surname: First Name: Middle Name: DOB


Patient # use 24 hours Location : > Retreatment
Time > Incident > Arrival > Depart > Employee # Yes >
Date Incident > mm / dd / yy > Sex > Male Female No >
Type of Accident > MVA Fire Landslide Illness Spill Work Acc Disaster False Alarm Others :
Personal Protective Equipment > Glove Mask Face Shield Gowns Eye Glass Class > A B C D Suit

WARNING - MAKE SURE THE SCENE SAFE BEFORE ENTERING THE SCENE
Gas > Yes No Electricity > On Off O2 Level > OK SCBA Power > On Off

Hazardous Material Spilled Type : Gasoline Gas Diesel Chemical Reagent Others :

Chief Complaint:
Patient/Incident

Number of Patients (circle) > Patients Version of Incident:

> 1 2 3 4 5 6 7
8 9 10 X >>> Above 10

Additional Help > Hospital Security Police Dept Other Dept :

Injury Code (Mark on figure) Main Condition/Problem


F > Fracture Abdominal Pain/Problem Fitting Convusing
L > Laceration > Allergies & Medical Reaction Headache
A > Abrasion Altered Level of Conciousness Heat/Cold exposure
H > Haemorrhage Back Pain OD/Ingestions/Poisonings
T > Tenderness Breathing Problems/Asthma Obstetric
C > Contusion Burns Stroke/C.V.A
D > Dislocation Cardiac Arrest Trauma
B > Burms Chest Pain (non traumatic) Trauma Penetrating
P > Pains Diabetic Problems Other (Non Specific)
R > Rigidity Electrocution/Electric Shock
S > Swelling Eye Problems/Injuries

Patient Status > Lying Sitting Standing


Airway Level of Conciousness Skin & Temperature Equipment
Breathing A Alert Normal Warm Cervical Collar
Circulation V Respond to Voice Pale Sweaty Spine Board
P Respond to Pain Cyanotic Hot Scoop Stretcher
Vital Signs
U Unresponsive Flushed/Red Cold S.K.E.D
Blood Pressure Respiration Pupils Breath Sounds K.E.D
Time Pulse
Systolic Diastolic Rate Size React Size React Airway
R L R L R L R L Manual Position
Suction
Oral Airway
HISTORY LMA
S Signs and Symptoms : Follow up Treatment/Referral O2 Therapy :
A Allergies : Medium Concentration
M Medication : Ambulance/Hospital High Concentration
P Pertinent History : Doctor 100% on Demand
L Last Oral Intake : Sent Home Litre / Minute
E Events prior to Incident : Further Re Treatment > 2- 6 6-10 12-15
Return to Work Other :

Treatment:

Initial/Call Sign

Team Name: Time All Clear by OSC > Team Captain >
TALENTA BUMI
EMERGENCY RESPONSE TEAM FORMAT PERAWATAN CEDERA / SAKIT

Nama lengkap : Tgl Lahir


Korban # Gunakan 24 jam Lokasi : > Rawat Ulang
Waktu > Kejadian > Tiba > Berangkat > Pekerja # Ya >
Tanggal Kejadian > Hari / Bulan /Tahun > Kelamin > Laki2 Perempuan Tdk >
Tipe Kejadian > MVA Fire Longsor Sakit Spill Kec Kerja Bencana Alarm Palsu Lain2
Alat Pelindung Diri > Gloves Mask Face Shield Gowns Eye Glass Class > A B C D Suit

PERINGATAN - YAKINKAN LOKASI AMAN SEBELUM MASUK


Gas > YA Tdk Listrik > On Off O2 Level > OK SCBA Power > On Off

Macam HazMat yang tumpah : Gasoline Gas Diesel Chemical Reagent Others :

Keluhan Utama :
Korban/Kejadian

Jumlah Korban (Lingkari ) : > Versi korban tentang kejadian :

> 1 2 3 4 5 6 7
8 9 10 X >>> Di atas 10

Bantuan Tambahan > Rumah Sakit Security Polisi Departemen Lain :

Kode Cidera ( Tandai ) Kondisi Utama/ Masalah


F > Patah Nyeri Perut/Masalah Bingung Tetap
L > Luka Gores > Alergi & Reaksi Obat Sakit Kepala
A > Lecet Tingkat Kesadaran Temperatur Panas/Dingin
H > Pendarahan Sakit Punggung OD/ Keracunan
T > Nyeri Tekan Masalah Pernapasan/Asma Kandungan
C > Luka Memar Luka Bakar Stroke
D > Dislokasi Henti Jantung Cedera
B > Luka Bakar Sakit Dada/Tidak Trauma Luka Tembus
P > Nyeri Masalah Diabetis Lain-Lain/tidak khusus
R > Kaku Tersengat Listrik
S > Bengkak Masalah Mata/Cedera

Status Korban > Berbaring Duduk Berdiri


Airway Tingkat Kesadaran Kulit & Suhu Peralatan
Breathing A Alert Normal Warm Cervical Collar
Circulation V Respond to Voice Pucat Berkeringat Spine Board
P Respond to Pain Cyanotic Hot Scoop Stretcher
Tanda Vital
U Unresponsive Kemerahan Cold S.K.E.D
Tekanan Darah Pernapasan Pupils Bunyi Napas K.E.D
Waktu Nadi
Systolic Diastolic Rata-Rata Normal Tdk Normal Normal Tdk Normal Airway
R L R L Manual Position
Suction
Oral Airway
R I W AYA T K O R B A N LMA
Perawatan
S Gejala & Tanda : O2 Therapy :
Lanjutan/Penyerahan
A Alergi : Medium Concentration
M Pengobatan : Ambulan/RumKit High Concentration
P Riwayat Sakit : Dokter 100% on Demand
L Makanan Terakhir : Dikirim Kerumah Liter/Menit
E Penyebab Kejadian : Perawatan Lanjutan > 2- 6 6-10 12-15
Kembali Bekerja Other :
Perawatan Yang Dilakukan :

Initial/Call Sign

Nama Tim : Waktu Selesai > Kapten Tim >