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Prehospital Patient Care Chart INCIDENT NUMBER UNIT ID INCIDENT DATE

INCIDENT ADDRESS INCIDENT CITY INCIDENT STATE INCIDENT ZIP CODE

INCIDENT COUNTY INCIDENT LOCATION TYPE

COMPLAINT REPORTED BY DISPATCH EMERGENCY MEDICAL DISPATCH PERFORMED LEVEL OF SERVICE

No Yes w/pre-arrival instructions BLS, Emergency
Yes w/out pre-arrival instructions ALS, Level 1 Emergency
INCIDENT/PATIENT DISPOSITION ALS, Level 2
Treated, Transport EMS No Patient Found Treated, Transferred care Treated, Transported Law Enforcement Specialty Care Transport
Cancelled No Treatment Required Pt Refused Care Helicopter
Treated & Released Dead at Scene Treated, Transported Private Vehicle Not Applicable
NUMBER OF PATIENTS ON SCENE MASS CASUALTY TYPE OF SERVICE REQUESTED PRIMARY ROLE OF THE UNIT
Single None Yes Scene Response ED to ED Transfer Transport Non-transport
Multiple No Mutual Aid Intercept Supervisor Rescue
TYPE OF DELAY (S)
DISPATCHER RESPONSE SCENE TRANSPORT RETURN
None-N/A None-N/A None-N/A None-N/A None-N/A
Not known Crowd Crowd Crowd Clean up
Caller Uncooperative Directions Directions Directions Decontamination
High Call Volume Distance Distance Distance Documentation
Language Barrier Diversion Diversion Diversion ED Overcrowding
Location (Inability to obtain) Hazmat Extrication>20 Min Hazmat Equipment Failure
No Unit Available Safety Conditions Hazmat Safety Conditions Equipment Replenishment
Safety Conditions Staff Delay Language Barrier Staff Delay Other
Technical Failure Traffic Safety Conditions Traffic Staff Delay
Other Ambulance Crash Staff Delay Ambulance Crash Ambulance Failure
Ambulance Failure Traffic Ambulance Failure
Weather Ambulance Crash Weather
Other Ambulance Failure Other
Weather
Other

AGE DATE OF BIRTH GENDER RACE ETHNICITY

Female Male
CURRENT MEDICATIONS ALLERGIES PERTINENT HISTORY

INJURY PRESENT CAUSE OF INJURY TYPE OF INJURY ALCOHOL/DRUG USE INDICATORS

Yes Blunt Penetrating None Pt admits to drug use
No Burn Not Known Smell of alcohol on breath Pt admits to alcohol use
Alcohol and/or drug paraphernalia at scene
CHIEF COMPLAINT

CHIEF COMPLAINT ANATOMIC LOCATION CHIEF COMPLAINT ORGAN SYSTEM

Abdomen Extremity Lower General/Global CNS/Neuro OB/GYN Pulmonary Endocrine/Metabolic
Chest Back Extremity Upper Global Renal Cardiovascular Gastrointestinal
Head Neck Genitalia Psych Skin Musculoskeletal
CARDIAC ARREST RESUSCITATION CAUSE OF CARDIAC ARREST
Yes, Prior to Arrival Defibrillation None-DOA Presumed Cardiac Respiratory
Yes, After Arrival Ventilation None-DNR Trauma Electrocution
No Chest Compressions None-Signs of life Drowning Other
USE OF SAFETY EQUIPMENT AIRBAG DEPLOYMENT
N/A Lap Belt Shoulder Belt Protective Clothing None Present Deployed Front
Not Known Helmet Worn Protective Non-Clothing Gear Other Not Deployed Deployed Side
Child Restraint Eye Protection Personal Floatation Device None Deployed Other N/A
BARRIERS TO STANDARD PATIENT CARE
Development Impaired Physically Impaired Unattended/Unsupervised Hearing Impaired
Physical Restraint Unconscious Language Speech Impaired
RESPONSE MODE TRANSPORT MODE Initial Call for Help Unit Left Scene
Lights/Sirens Unit Notified Patient arrived at Destination
No Lights/No Sirens Unit En Route Incident Completed

Initial Lights/Sirens Downgraded to no Lights/Sirens Arrive on Scene Available for Next Incident

Initial No Lights/Sirens Upgraded to Lights/Sirens Arrived at PT.

PRIOR AID
PRIOR AID OUTCOME Improved Unchanged Worse Unknown

PERFORMED BY MEDICATIONS/ PROCEDURES PERFORMED BY MEDICATIONS/PROCEDURES

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 INCIDENT NUMBER UNIT ID INCIDENT DATE

TRAUMA TRIAGE CRITERIA

2nd/3rd burn >10% BSA or Flail chest ADULTS ONLY
face/feet/hand/genital/airway Torso inj w/abd tender/ distended/seatbelt sign Pulse >120 w/hemor shock PEDS ONLY
Amp prox to wrist/ankle LOC >5 min Tension pneumothorax Poor perfusion
Decreasing LOC Mech of inj Resp <10 or >29 Resp distress/failure
GCS Motor <4 Did not meet any triage criteria Required intubation
GCS Total <13 Pen inj head/neck/torso SysBP <90, or no radial pulse
Head/neck/torso crush Pen inj prox to knee/elbow w/neurovasc comp w/carotid pulse
Extremity inj w/neurovasc comp Spinal cord inj
Extremity crush Special Considerations
Torso inj w/pelvic fx 2+ prox humerus/femur fxs
SYMPTOMS PRIMARY=P ASSOCIATED=A PROVIDER IMPRESSION PRIMARY=P SECONDARY=S
P A P A P S P S P S
None Mass/Lesion Abd pain Electrocution Resp arrest
Bleeding Mental/Psych Airway obstruct Hyperthermia Resp distress
Breathing Nausea/Vomiting Allergic rxn Hypothermia Seizure
Changes in Responsiveness Pain Altered LOC Hypovolemia/shock Sexual assault/rape
Choking Palpitations Behavior/psych Inhalation/toxic gas Stings/bites
Death Rash/Itching Cardiac arrest Inhalation/smoke Stroke/CVA
Device/Equip Prob Swelling Cardiac arrhythmia Death Syncope
Diarrhea Transport Only Chest pain Poisoning/drug OD Injury
Drainage/Discharge Weakness Diabetic OB/delivery Vag bleed
Fever Wound
Malaise
MEDICATIONS
TIME MEDICATION DOSE ROUTE REACTIONS

PROCEDURES
TIME PROCEDURE # ATTEMPTS SUCCESSFUL COMPLICATIONS
YES NO

YES NO
YES NO
YES NO
YES NO
VITAL SIGNS
TIME PULSE SYS BP DIA BP RESP O2 SAT GCS EYE GCS VERBAL GCS MOTOR

ADV DIRECTIVE DESTINATION

State DNR Form Family Request DNR (no form) Living Will
Other Healthcare DNR None Other
TYPE OF DESTINATION REASON FOR CHOOSING DESTINATION ED DISPOSITION HOSPITAL DISPOSITION
Hosp ED/OR/L&D Closest On-line Med Control Admit-floor Death
Other EMS (air) Diversion Other Admit-ICU Discharge
Other EMS (ground) Family Choice Pt. Choice Death Transfer-other hosp
Other Insurance Pt. Physician’s Choice Discharge Transfer-nursing home
Law Enforcement Choice Protocol Transfer-other hosp Transfer-other
Transfer-rehab
NARRATIVE

CREW MEMBER CREW MEMBER CREW MEMBER

CREW MEMBER CREW MEMBER CREW MEMBER

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Incident Location Type Cause of Injury Codes

Field Values Field Values

-25 Not Applicable -25 Not Applicable
-15 Not Reporting -15 Not Reporting
-10 Not Known -10 Not Known
-5 Not Available -5 Not Available
1135 Home/Residence 9500 Aircraft related accident (E84X.0)
1140 Farm 9505 Bicycle Accident (E826.0)
1145 Mine or Quarry 9510 Bites (E906.0)
1150 Industrial Place and Premises 9515 Chemical poisoning (E86X.0)
1155 Place of Recreation or Sport 9520 Child battering (E967.0)
1160 Street or Highway 9525 Drowning (E910.0)
1165 Public Building (schools, gov. offices) 9530 Drug poisoning (E85X.0)
1170 Trade or service (business, bars, restaurants, etc) 9535 Electrocution (non-lightning) (E925.0)
1175 Health Care Facility (clinic, hospital, nursing home) 9540 Excessive Cold (E901.0)
1180 Residential Institution (Nursing Home, jail/prison) 9545 Excessive Heat (E900.0)
1185 Lake, River, Ocean 9550 Falls (E88X.0)
1190 Other Location 9555 Fire and Flames (E89X.0)
9560 Firearm assault (E965.0)
9565 Firearm injury (accidental) (E985.0)
9570 Firearm self inflicted (E955.0)
9575 Lightning (E907.0)
9580 Machinery accidents (E919.0)
9585 Mechanical Suffocation (E913.0)
9590 Motor Vehicle non-traffic accident (E82X.0)
9595 Motor Vehicle traffic accident (E81X.0)
9600 Motorcycle Accident (E81X.1)
9605 Non-Motorized Vehicle Accident (E848.0)
9610 Pedestrian traffic accident (E814.0)
9615 Radiation exposure (E926.0)
9620 Rape (E960.1)
9625 Smoke Inhalation (E89X.2)
9630 Stabbing/Cutting Accidental (E986.0)
9635 Stabbing/Cutting Assault (E966.0)
9640 Struck by Blunt/Thrown Object (E968.2)
9645 Venomous stings (plants, animals) (E905.0)
9650 Water Transport accident (E83X.0)