Medical Report

Patient: DOB Tel.:

Acc. Person:
Actual Diagnosis :
further Diagnosis :

Hospital : Tel.:
Ward: Room:
Contact person : Tel.:

Destination hospital : Tel.:

Contact person : Tel.:

Patient history :

Patients status date: Glasgow Coma Scale (GCS) :

Body weight:
Mobility:
Nutrition:
Actual lab. test results : Haemoglobin :

Breathing : O spontaneous
Demand of oxygen : l/min
O ventilated : O ASB O BIPAP O2 % insp.:
O SIMV O CPAP PIP (mbar):
Saturation (%) : O IPPV PEEP (mbar) :
Blood gas (art.): ph: Base excess(BE): Po2: pCo2:
Circulation : Blood pressure: Heart rate: O stable O unstable
Catecholamins: O Dopamine µg/kg/min
O Dobutamine µg/kg/min
O Epineprhrine / Suprarenine µg/kg/min
O Noradrenaline µg/kg/min
Catheter : O CVC (central venous catheter) O peripher O arteria

All Drugs:: O Syringe pumps :

i.v.:

oral:

Drains: O no O yes :
Vesical catheter ? O no O yes :
Pneumothorax ? O no O yes :
Infectious diseases / MRSA / ESBL...? O no O yes :
In the opinion of his doctor fit to fly ? O no O yes :