PATIENT NAME (Last, First, Middle)

PATIENT NAME (Last, First, Middle) SSN# MO DAY YEAR DAY OF WEEK

PT HOME OR MAILING ADDRESS NAME RESPONS. PARTY/RELATIONSHIP RUN INFORMATION SERVICE DOB AGE SEX PHONE PT’S PHYSICIAN UNIT ID NO.

INCIDENT: STREET, CITY, ZIP REASON FOR DISPATCH RUN NO.

CALL RECEIVED AID BEFORE ARRIVAL CODE Gearhart Fire Prearrival Instructions Y N 911 Dispatch Code to scene MCI Dept. First Aid P F Q O Change in Code Direct Call MPS EMS Prehospital CPR P F Q O Code to Destination PT # Care Report Walk in Change in Code Extrication P F Q O Total # PTs Other: None P F Q O at scene First Resp. Unit INCIDENT SITE: TOTAL SCENE TIME: mins TIMES MILTARY TIME TRANSPORT Home/Personal Residence Reason, If Prolonged (> 10 mins.) Est Time of Event PT WAS TRANSPORTED Y Adverse Weather Call Recd 911/Disp N Farming Adverse Road Conditions LEVEL OF SERVICE BLS ILS Logging ALS Vehicle Problems Industrial Place Dispatched TO: Unsafe Scene QRU Responded Recreation/Sports Facility QRU at Scene Language Barrier Freeway/Highway TR Amb Responded BY: HazMat TR Amb at Scene City/County Street Helicopter Landed Crowd Control With Patient RECEIVED BY: Public Building Patient Transferred Other Residential Institution PT Depart Scene Extrication > 10 mins PT Arrive @ Hosp ONLINE MEDICAL CONSULTATION Other: Cancelled Call Y N Unable Extrication Time: mins Ready for Next Call Time PERSONAL PROTECTIVE IF VEHICULAR PAST MEDICAL HISTORY NATURE OF CALL (check one only) EQUIPMENT PATIENT WAS: No past history CARDIAC ARREST MVA Y N Protection Dev: In/On Inv. With Lap Heart Condition CHEST PAIN Car Gloves Shoulder Truck COPD or Lung Disorder DIFFICULTY GUNSHOT Bus Eye Protect. Air Bag Depl. C Cancer BREATHING Motorcycle H SEIZURE STABBING Helmet Bicycle E CVA/Stroke Mask Child Seat Stat. Object C DIABETIC Diabetes Other K DOMESTIC Gown Clothing OVERDOSE Hypertension VIOL. Float A OTHER MEDICAL L Seizures OTHER Other Unknown L NEUROLOGICAL Unknown ASSAULT T OTHER H Other: A BEHAVIORAL/PSYCH TRAUMA T A P MATERNITY/ P OB L Y FIRE/OTHER STBY NO PATIENT GLASGOW COMA SCORE INVASIVE PROCEDURES EYE OPENING VERBAL RESPONSE MOTOR RESPONSE Procedure Attempt Success Spontaneous 4 Oriented 5 Obeys commands 6 ET Paralytics Y N To voice 3 Confused 4 Localizes pain 5 PEAD End-tidal CO Y 2 N To pain 2 Inappropriate words 3 Withdraws (pain) 4 CRIC Detect None 1 Incomprehensible 2 Flexion (pain) 3 Comments: None 1 Extension (pain) 2 NEEDLE THORAC. None 1 Total IV/IO Time Solution: Amt. Infused: ml

T MANDATORY ENTRY CRITERIA DISCRETIONARY WITH HIGH INDEX OF SUSPICION R VITAL RESPONSE Spinal cord injury with limb COMORBID FACTORS HIGH ENGERY TRANSFE I Syst. BP < 90 mmHg Age (<5 or >55) paralysis A Fall > 20 ft. Bleeding disorder G Resp. distress w/ rate < 10 or > 29 Flail chest or on anti coagulants E Airway management required Ped hit at 20 mph or Two or more obvious fractures Cardiac/resp. thrown 15 ft. C GCS ≤ 12 of femur or humerus disease, diabetes, R Rollover cirrhosis, or morbid MECHANISM OF INJURY I ANATOMY OF INJURY obesity ENTERED INTO Death of same car occupant MC, ATV, Bicycle crash T Penetration injury to head, neck, torso Pregnancy TRAUMA E or groin PT ejected from enclosed Impact/Significant R Immunosuppressed SYSTEM Intrusion I Amputation above wrist or ankle vehicle Presence of A Heavy extrication time > 20 Y N intoxicants C mins. Other TIME OF H E ENTRY C K

TRAUMA A L ID# L

T H A T

A P P L Y R I have refused prehospital medical care. I have been informed of the potential risk SIGNATURE OF PT/GUARDIAN DATE TIME E F involved. I release the rescue/ambulance personnel from responsibility for U any ill effects which may result from my actions. WITNESS WITNESS S A Refused transport Refused prehospital L care Refused to sign FLOW CHART PATIENT NAME: DATE:

Time Treatment/Intervention Performed By BP Pulse Resp LOC/GCS SaO2

CURRENT MEDICATION(S):

ALLERGIES: NARRATIVE or S(ubject) O(bjective) A(ssessment) P(lan) History Physical Exam Clinical Impression Treatment enter narrative here

CLINICAL IMPRESSION(S) enter assessment here

EMS Personnel Certification Pd/Vol EMS Personnel Certification Pd/Vol 1. T 1. T Pd/Vol Pd/Vol 2. T 2. T

Personal Belongings Entrusted To: Signature of Person Writing Report