Unit Information Date Agency Name Agency Number

Preliminary Type of Service Requested

Report*
911 Resp. (Scene)
Interfacility Trans.
Transport Unit # Call Sign # EMT B / I / P EMT B / I / P PCR # Medical Trans. Standby
Revision 2 Intercept Mutual Aid
Patient Name Age Date of Birth Sex Phone Number Work Related/Occup.
M F
Patient Address City State Zipcode Race/Eth. Social Security Number

Legal Guardian if Patient is a Minor Relation to Patient Insurance Company

Location / Address of Call or Incident Other Agencies

Same as Above
Response Mode to Scene Dispatch Complaint EMD Performed
Lights and Sirens No Lights and Sirens Downgraded to No L&S Upgraded to L&S EMD Card #
AED Prior to Arrival Arrest Witnessed By Downtime Performed By: Mechanism or Cause? PSAP Call Date/Time
Yes No
CPR

On Scene Prior EMS/1st R/PD < 5 minutes EMS/1st R

Situation

to EMS Time Started Family 5-10 minutes PD Unit Notified by Dispatch Date/Time
Bystander 10-15 minutes Family
Yes No Unknown Unknown Bystander
Steering Wheel Deformity

Mechanism of Injury
Windshield Spider
Chief Complaint Unit En Route Date/Time

DATES and TIMES

Dash Deformity Lap Seat Belt
Side Post Deformity Shoulder Belt Unit Arrived on Scene Date/Time
Duration
Min Hrs Days Severity (1-10) Ejection Helmet
Other Complaints DOA Same Vehicle Infant Carseat Arrived at Patient Date/Time
Rollover Airbag
Space Intrusion > 1 ft. Unit Left Scene Date/Time
Duration Min Hrs Days Severity (1-10)
Fire
Time BP HR RR Glucose CO2 SaO2 Temp. Patient Arrived at Destination Date/Time
Vital Signs

Extraction Time (min) Unit Back in Service Date/Time

Fall (ft)
Unit Back at Home Location Date/Time
(Circle Pt. and
Vehicle Impact Area) Beginning Odometer
Car
Meds

ODOMETER
Past History

Sport Utility On-Scene Odometer

Stationwagon
Truck
Van Destination Odometer
Evidence of Alcohol Ingestion? Yes No DNR/MOST Form Living Will Motorcycle
Allergies Bicycle Loaded Mileage
Boat
Patient Survey

Denies
Narrative

Protocols Used
Skin HEENT / Neck Chest Heart Abdomen Pelvis / Gen. Extremities Back
Normal Normal BS Normal Normal Tenderness Abnormalities Normal
Pale Normal Normal Tender Sp. Process
Decreased BS Decreased Sounds Normal
Cyanotic JVD Distention No C T L
Tenderness Murmur Tender
Clammy Tracheal Dev. Acc. Muscles Monitor/ECG/FHT’S
Tenderness Unstable RUE Tender Paraspinous
Guarding No C T L
Jaundiced SQ Air Flail Segment Mass Genital Injury LUE
Cold Stridor Rhonchi / Wheezing 1 Crowning Pain to ROM
Warm Lac. / Lesion Rales Lac./Lesions Lac./Lesions RLE No C T L
Diaphoretic 2 R L UQ LQ LLE Lac./Lesions
Lac. / Lesion
Pupils Findings Deficit Stroke Screen
Glasgow Coma Neuro

L: React. Dil __ mm Nonreact. Blind Normal Confused Unresponsive Seizures Obtunded Dysphasia Positive
R: React. Dil __ mm Nonreact. Blind Combative Hallucinations Post-ictal Tremors Hemiplegia: R L Negative
Spontaneous 4 Oriented 5 Obeys Commands 6 Total Total
Adult Trauma

10 - 29 =4 > 89 =4 13 - 15 =4
Systolic BP

GCS Points

Confused
Resp. Rate

To Voice 3 4 Localizes to Pain 5 GCS Reperfusion

> 29 =3 76 - 89 =3 9 - 12 =3 Adult Trauma
Verbal

Motor
Scale

To Pain Inappropriate Sounds 3 Withdraws (Pain) Check Sheet

Eyes

2 4
Score

Score 6 - 9 =2 50 - 75 =2 6 - 8 =2 Score
None 1 Incomprehensible Sounds 2 Flexion (Pain) 3 No Contraindicators
1 - 5 =1 1 - 49 =1 4 - 5 =1
None 1 Extension (Pain) 2 Contraindicators
None =0 None =0 3 =0
None 1
Time Procedure Size Tech State ID Success Time Medication Dose/Route Tech State ID
Procedures & Medications

Y N
Y N
Y N
Y N
Y N
ETT Confirmation and Signature at Destination Time Cardiac Rhythm or 12 Lead Interpretation

Transport Mode from Scene

Disposition

Lights and Sirens No Lights and Sirens Downgraded to No L&S Upgraded to L&S
Patient’s Condition Reason for Choosing Destination (circle) Treatment Authorized by MD MICN
Transport Moved to Ambulance Transport Position Safety on Arrival Diversion Closest Facility
Refused Walk Prone Supine Gloves Improved Insurance Status Family Choice
Cancelled Stretcher L. Lateral Sitting Mask Same On-Line Medical Direction Law Enforcement Choice
Carry Trendelenberg Head Elevated Gown Patient Choice Patient’s Physician Choice
Patient Received by
Worse
Stairchair Fowlers Eyewear Protocol Specialty Resource Center
EMT Signature
Destination Name and/or Address EMT-P State ID Medical Control Signature

* This is a preliminary document. This is not the final EMS Patient Care Report.