New Hampshire Pcr
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View New Hampshire Pcr as PDF for free.
More details
- Words: 903
- Pages: 2
077584 I.S
FIRST RESPONSE
C}
Z
Service #
z t= «
Bystander
Cl.
0 First Responder Service
0 0
Prior Care by: Aid Given:
Arrival Time
First Responder Moved Patient
0 0
0 0
MDIAN
CPR
Fire
Othe~
0
Police
0
~
~
:2:
«
TYPE OF AMBULANCE RESPONSE
0 0
TO Scene: FROM Scene:
-
Emergency
Transport
o Mutual o
o Non-Emergency
Aid
o
Transfer
No Transport
0
0
MECHANISM OF INJURY
TYPE OF CALL
o Allergic Reaction o Behavioral o Cardiovascular o Diabetic o Gastrointestinal o HeaVHyperthermia o Hypothermia/Frostbite o Neurological o OblGyn o Poisoning/Overdose o Respiratory o Toxic Exposure o Trauma o Urinary Tract o Vascular o OTHER:
Care Refused
SCENE
o Farm o Home o Industrial o Logging
o Vehicle Type:
o Air Bag Inflated o Restraint used o Child restraint o Helmet used
o Medical Facility o Public BuildingIPlace o Recreational o School o StreeVHighway o OTHER:
o Drowning/Suffocation o Electrical o Fall o Fire o Organized Sports o StablGunshot
o TooVObject:
Cancelled En Route
o
0 0 0
EOA
o OTHER:
ET NTT
o CPR o Gardioversion X o Defibrillation X o Monitoring o o
successful successful
Suction
Um
Simple Mask
Um
Non-rebreather
um
o BREATHING Assisted o Bag Valve Mask o Demand Valve o Pocket Mask o BLEEDING Controned o Bandage/Dressing Applied o Intraosseous infusion o IV attempted 0 successful MAST inflated:
0
Legs
0
w
-' CO
~
o o
~
a:
z
z
::::> -'
::::>
CO
CO
"0
CD
::::;: ~
0
0
~
C)
en en
0 "uu
a:
o NauseaIVomiting
Cardiac Arrest
z
-'
i=
tJ::
(fJ
en >
0
en 0 z
-'
« a: «Cl.
z
;( Cl.
::l
0
3:
Eye Opening Response
o
Respiratory Arrest
D
OTHER:
o Vision Impaired
REVISED TRAUMA SCORE
SPONTANEOUS
4
TO VOICE
3
TO PAIN
2
NONE
1
13-15 GLASGOW COMA 9-12 SCALE (GCS) 6-8 (Total points from left) 4-5
4 3 2
ORIENTED
5
3
0
CONFUSED
4
> 89 mm HG
4
INAPPROPRIATE WORDS
3
76-89 mm HG
3
50-75 mm HG
2
Systolic
Blood
Pressure
INCOMPREHENSIBLE SOUNDS 2 _
NONE
1
1-49 mm HG
1
_
OBEYS COMMANDS
6
No Pulse
0
Best Motor Response
Pacing Drug Administration
LOCALIZES PAIN
5
WITHDRAWS (PAIN)
4
Respiratory
Rate
10-29/min
4
> 29.min
3 2
FLEXION (PAIN)
3
6-9/min
EXTENSION (PAIN)
2
1-5/rnin
NONE
1
None
0
Long Board Bum Care
o Chest Decompression o o o
Sling/Swathe Splint, type:
Retationship
Guarantor's Name
Splint, traction
o OBIGYN Care/Childbirth o o
Pllone •
Restraint applied OTHER CARE:
State
Abdomen
ODOMETER
MILEAGE
...,_IIIIiI-.
DESTINATION
Initial VITAL SIGNALS: PATIENT DISPOSITION:
uu
z t: en en uu z
« en z uu en
o Cold/Shivering o Dizziness/Fainting o Hot/Feverish
o Breathing Difficulty
o Extrication o Cervical Imm'JIJilization o Short Board
Cricothyroid Needle Puncture
o Cannula o o
o Altered Mental Status o Apparent Death
TRAUMAGare
OXYGEN Administered
(5
en en
z
SIGNS and SYMPTOMS
Best Verbal Response
CARDIAC Care
successful
z
uu
::::i
uu
3: en
en a: 0 i=::
::::>
GLASGOW COMA SCALE
o AT WORK o Hazardous Materials o Mass Casualty
CARE GIVEN PATIENT
o o o o o
C)
C}
i=
0
HEAD FACE I EYE I EAR NECK I THROAT CHEST BACK ABDOMEN UPPER ARM I SHOULDER LOWER ARM I ELBOW I HAND UPPER LEG I HIP LOWER LEG I KNEE I FOOT
(0
Specify
o AIRWAY Opened o Manually Cleared o Nasopharyngeal o Oropharyngeal
I
Z
::::i
-'
B/P:
LOADED MILES
SIGNATURE Of PERSON RECEIVING PATIENT:
o o
Medicare Private Insurance
D D
Medicaid
_
Private No Insurance
I RESP.
PULSE
o ADMITTED ICU/CCU o ADMITTED MEDISURG o DISCHARGED HOME D DOA
SPECIAL BILLING INSTRUCTIONS: (Social Security #. Other Insurance, etc.)
0 0
ADMITTED TO SURGERY DIED
D D
0 0
Workman's Compo VA
I TEMP.
DISCHARGED Other: TRANSFERRED TO
D
Trauma Team Activated
D
Other
o
NEW HAMPSHIRE EMS Patient Record
I 1---.LL.BmI
EmiEI
NH Lie #
~
Call #
Year
Meds Rx:
I
-
Medical Facility or Street
PAST MEDICAL HISTORY Allergies
I
/ /
Mo. Day
584
I
State
CityfTown
Pertinent MediSurg. Hx: Last
First
M.I.
I
Address
Medical I. D. lor:
CityfTown
Day
Year
Sex
Weight
Patient's MD
EMS RESPONSE TIMES
:--,--2,----;;3,--,---_4_ _ :;-_--;:-_ Patient Status ,-_-'-'.:::::.=.:=;
EIIIl-::-:-:c----:-:---------_ _--=----::Relationship
ZIP
State
BlL_--'---' __---lEII'-----_---'--'D=--;;F,--D=---'M-'--_~,...,..,...-..L...----=1 Mo.
Phone #
ITIIJ ITIIJ ITIIJ
ITIIJ ITIIJ ITIIJ
DISPATCH
c.==---..:._--J..
Phone #
RESPONDING
ARRIVE SCENE
--------CHIEF COMPLAINT
TIME
(24 Hour)
L.O.C.
PULSE
o Regular 0
AV 1_-.JL--l._--'-_+--:-:-:---'p'-U"'-j
BP Irreg
RESPIRATIONS
0
Normal
0
Abnormal
LUNG SOUNDS L
R SOUNDS
AV
0
PU
AV
Time
L
PUPILS R
o o o
0 SIron 0 Regular 0 Stron 0 Regular
..
Irreg Wea Irreg Wea
Treatment
0 0 0 0
0 Labored 0 Normal 0 Labored 0 Normal
Abnormal
Stridor Rales
Shallow
Rhonchi
Abnormal
Wheezes
Shallow
Unreactive
Constricted ;
o o
Dilated Unequal
IN SERVICE
SKIN D
Reactive
-:=O::-:s:::t:;:ro::n!L..:O=_-'-W:..::e::::a"lk----'---+---..:O=_..::La:::b::::o:;:re::::d-:=O::-:S:::.h:::a:::llo:::w'--l_-l--l Clear 0 Regular 0 Irreg 0 Normal 0 Abnormal Absent
AV 1_~L--l.---'--+--:-:-:---'p'-=U+----=O::-:s:::t:;:ro::ng!L..:O=_-'-w:..::e""'l_---'---+---..:O=_..::La:::bo=red:::.-::O::-:S:::.h:::a:::llo:::w'--l_-l--l
MEDICAL CONTROL
AT HOSPITAL
LEAVE SCENE
0 D 0
TEMPERATURE
Normal Cyanolic M
o
Normal
D
Warm/Hot
D
CooVCoid
t OIS
Flushed
D.p.ale• • • C/F •
D1SCOr1Jugate
L _mm
R_mm
1 3
5
7
9
NH ALS#
Results/Observations
Verbal Order • Standing Order •
Name of Physician:
Signature, Primary Care Attendent
AMBULANCE CREW
and LICENSE #:
Original - Service
WHITE COPY - HOSPITAL
Yellow Copy - EMS
Green Copy - EMS Hosp Coor
FIRST RESPONSE
C}
Z
Service #
z t= «
Bystander
Cl.
0 First Responder Service
0 0
Prior Care by: Aid Given:
Arrival Time
First Responder Moved Patient
0 0
0 0
MDIAN
CPR
Fire
Othe~
0
Police
0
~
~
:2:
«
TYPE OF AMBULANCE RESPONSE
0 0
TO Scene: FROM Scene:
-
Emergency
Transport
o Mutual o
o Non-Emergency
Aid
o
Transfer
No Transport
0
0
MECHANISM OF INJURY
TYPE OF CALL
o Allergic Reaction o Behavioral o Cardiovascular o Diabetic o Gastrointestinal o HeaVHyperthermia o Hypothermia/Frostbite o Neurological o OblGyn o Poisoning/Overdose o Respiratory o Toxic Exposure o Trauma o Urinary Tract o Vascular o OTHER:
Care Refused
SCENE
o Farm o Home o Industrial o Logging
o Vehicle Type:
o Air Bag Inflated o Restraint used o Child restraint o Helmet used
o Medical Facility o Public BuildingIPlace o Recreational o School o StreeVHighway o OTHER:
o Drowning/Suffocation o Electrical o Fall o Fire o Organized Sports o StablGunshot
o TooVObject:
Cancelled En Route
o
0 0 0
EOA
o OTHER:
ET NTT
o CPR o Gardioversion X o Defibrillation X o Monitoring o o
successful successful
Suction
Um
Simple Mask
Um
Non-rebreather
um
o BREATHING Assisted o Bag Valve Mask o Demand Valve o Pocket Mask o BLEEDING Controned o Bandage/Dressing Applied o Intraosseous infusion o IV attempted 0 successful MAST inflated:
0
Legs
0
w
-' CO
~
o o
~
a:
z
z
::::> -'
::::>
CO
CO
"0
CD
::::;: ~
0
0
~
C)
en en
0 "uu
a:
o NauseaIVomiting
Cardiac Arrest
z
-'
i=
tJ::
(fJ
en >
0
en 0 z
-'
« a: «Cl.
z
;( Cl.
::l
0
3:
Eye Opening Response
o
Respiratory Arrest
D
OTHER:
o Vision Impaired
REVISED TRAUMA SCORE
SPONTANEOUS
4
TO VOICE
3
TO PAIN
2
NONE
1
13-15 GLASGOW COMA 9-12 SCALE (GCS) 6-8 (Total points from left) 4-5
4 3 2
ORIENTED
5
3
0
CONFUSED
4
> 89 mm HG
4
INAPPROPRIATE WORDS
3
76-89 mm HG
3
50-75 mm HG
2
Systolic
Blood
Pressure
INCOMPREHENSIBLE SOUNDS 2 _
NONE
1
1-49 mm HG
1
_
OBEYS COMMANDS
6
No Pulse
0
Best Motor Response
Pacing Drug Administration
LOCALIZES PAIN
5
WITHDRAWS (PAIN)
4
Respiratory
Rate
10-29/min
4
> 29.min
3 2
FLEXION (PAIN)
3
6-9/min
EXTENSION (PAIN)
2
1-5/rnin
NONE
1
None
0
Long Board Bum Care
o Chest Decompression o o o
Sling/Swathe Splint, type:
Retationship
Guarantor's Name
Splint, traction
o OBIGYN Care/Childbirth o o
Pllone •
Restraint applied OTHER CARE:
State
Abdomen
ODOMETER
MILEAGE
...,_IIIIiI-.
DESTINATION
Initial VITAL SIGNALS: PATIENT DISPOSITION:
uu
z t: en en uu z
« en z uu en
o Cold/Shivering o Dizziness/Fainting o Hot/Feverish
o Breathing Difficulty
o Extrication o Cervical Imm'JIJilization o Short Board
Cricothyroid Needle Puncture
o Cannula o o
o Altered Mental Status o Apparent Death
TRAUMAGare
OXYGEN Administered
(5
en en
z
SIGNS and SYMPTOMS
Best Verbal Response
CARDIAC Care
successful
z
uu
::::i
uu
3: en
en a: 0 i=::
::::>
GLASGOW COMA SCALE
o AT WORK o Hazardous Materials o Mass Casualty
CARE GIVEN PATIENT
o o o o o
C)
C}
i=
0
HEAD FACE I EYE I EAR NECK I THROAT CHEST BACK ABDOMEN UPPER ARM I SHOULDER LOWER ARM I ELBOW I HAND UPPER LEG I HIP LOWER LEG I KNEE I FOOT
(0
Specify
o AIRWAY Opened o Manually Cleared o Nasopharyngeal o Oropharyngeal
I
Z
::::i
-'
B/P:
LOADED MILES
SIGNATURE Of PERSON RECEIVING PATIENT:
o o
Medicare Private Insurance
D D
Medicaid
_
Private No Insurance
I RESP.
PULSE
o ADMITTED ICU/CCU o ADMITTED MEDISURG o DISCHARGED HOME D DOA
SPECIAL BILLING INSTRUCTIONS: (Social Security #. Other Insurance, etc.)
0 0
ADMITTED TO SURGERY DIED
D D
0 0
Workman's Compo VA
I TEMP.
DISCHARGED Other: TRANSFERRED TO
D
Trauma Team Activated
D
Other
o
NEW HAMPSHIRE EMS Patient Record
I 1---.LL.BmI
EmiEI
NH Lie #
~
Call #
Year
Meds Rx:
I
-
Medical Facility or Street
PAST MEDICAL HISTORY Allergies
I
/ /
Mo. Day
584
I
State
CityfTown
Pertinent MediSurg. Hx: Last
First
M.I.
I
Address
Medical I. D. lor:
CityfTown
Day
Year
Sex
Weight
Patient's MD
EMS RESPONSE TIMES
:--,--2,----;;3,--,---_4_ _ :;-_--;:-_ Patient Status ,-_-'-'.:::::.=.:=;
EIIIl-::-:-:c----:-:---------_ _--=----::Relationship
ZIP
State
BlL_--'---' __---lEII'-----_---'--'D=--;;F,--D=---'M-'--_~,...,..,...-..L...----=1 Mo.
Phone #
ITIIJ ITIIJ ITIIJ
ITIIJ ITIIJ ITIIJ
DISPATCH
c.==---..:._--J..
Phone #
RESPONDING
ARRIVE SCENE
--------CHIEF COMPLAINT
TIME
(24 Hour)
L.O.C.
PULSE
o Regular 0
AV 1_-.JL--l._--'-_+--:-:-:---'p'-U"'-j
BP Irreg
RESPIRATIONS
0
Normal
0
Abnormal
LUNG SOUNDS L
R SOUNDS
AV
0
PU
AV
Time
L
PUPILS R
o o o
0 SIron 0 Regular 0 Stron 0 Regular
..
Irreg Wea Irreg Wea
Treatment
0 0 0 0
0 Labored 0 Normal 0 Labored 0 Normal
Abnormal
Stridor Rales
Shallow
Rhonchi
Abnormal
Wheezes
Shallow
Unreactive
Constricted ;
o o
Dilated Unequal
IN SERVICE
SKIN D
Reactive
-:=O::-:s:::t:;:ro::n!L..:O=_-'-W:..::e::::a"lk----'---+---..:O=_..::La:::b::::o:;:re::::d-:=O::-:S:::.h:::a:::llo:::w'--l_-l--l Clear 0 Regular 0 Irreg 0 Normal 0 Abnormal Absent
AV 1_~L--l.---'--+--:-:-:---'p'-=U+----=O::-:s:::t:;:ro::ng!L..:O=_-'-w:..::e""'l_---'---+---..:O=_..::La:::bo=red:::.-::O::-:S:::.h:::a:::llo:::w'--l_-l--l
MEDICAL CONTROL
AT HOSPITAL
LEAVE SCENE
0 D 0
TEMPERATURE
Normal Cyanolic M
o
Normal
D
Warm/Hot
D
CooVCoid
t OIS
Flushed
D.p.ale• • • C/F •
D1SCOr1Jugate
L _mm
R_mm
1 3
5
7
9
NH ALS#
Results/Observations
Verbal Order • Standing Order •
Name of Physician:
Signature, Primary Care Attendent
AMBULANCE CREW
and LICENSE #:
Original - Service
WHITE COPY - HOSPITAL
Yellow Copy - EMS
Green Copy - EMS Hosp Coor
Related Documents
New Hampshire Pcr
April 2020 2
New Hampshire
December 2019 14
New Hampshire State Snapshot
June 2020 11
2003 New Hampshire
June 2020 5
New York State Pcr
April 2020 11