New York State Fr Pcr
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- Pages: 2
Prehospital Care Report ~ ~ DATE OF CALL
Iii iii I
FOR BLS FR USE ONLY l----ri-r-i-'--i"'--iII iii
RUN NO.
AGENCY COOE
Name
Agency -+N:'.:.a:'.:.m.c::e Dispatch Information
I-:-c-c,-Address
MILEAGE - l END
CALL REC'D
I=~~~== -------+L~~~~-------------------------__ ~T-m~Al~:~~~~ A~R~~¥~~ I CHECK 0 Residence 0 Health Facility 0 farm 0 Indus. facility I --..".... .+::~ON.:7'E__=:=:=O':_Oth:-:::er:;;w~Or1<::--lOCr.---'O=--R-oa-'-dWa....:Y'---=O=-R-'-ec-'-re-'-at.c.iO".c.al_O=-o_In_er .............._ ............._-1 FROM SCENE ==*=:;=:;=:::; F CALL TYPE AS REC'O COMPLETE FOR TRANSFERS ONLY I -=,--,-,0=i 0 Emergency Transferred from ITIJ AT DESTIN BEGIN:
ENRDUTE
r-----------------------------------~C~I------------------------------r--+'-r+-r+~
r-
o r__
o Non-Emergency -l.--=O"-S""ta"'n""d--"BL-_ _-1
!-;;-:--;::-;:-.,.,.,...,===:-::-:"....,.,=,.,.,..,-
CARE IN PROGRESS ON ARRIVAL: o None 0 Citizen 0 PD/FD/Other First Res onder
o o
MVA () seat belt used ...... ) Struck b vehicle"'---
~1~iIPlllitPiijlllt!~j
l : : : __
1=:;=:::;:::=*=
0 No Previous PCR 0 Unknown if Previous PCR
0 Other EMS
Previous PCR Number
D- ITIIJJJ
0 Extrication required Seat belt used? minutes 0 Yes 0 No 0 Unknown
-='-=,iii
IN SERVICE
==::=~=:==
I IN QUARTERS
Se~\~elt 0 Crew Re orted B 0 Police
o Patient o Other
I
PRESENTING PROBLEM
o
Allergic Reaction 0 Syncope Airway Obstruction 0 Stroke/CVA Respiratory Arrest 0 Generallllness!Malaise Respiratory Distress 0 G~stro:lntestinal Distress Cardiac Related (Potential) 0 Diabetic Related (Potential) Cardiac Arrest 0 Pain ======
If more than one checked. circle primary
o
o
o
o
o
o o
o o
o
Unconscious/Unresp. 0 Shock Seizure 0 Head Injury Behavioral Disorder 0 Spinal Injury Substance Abuse (Potential) 0 Fracture/Dislocation Poisoning (Accidental) 0 Amputation
o Major Trauma
o Trauma-Blunl o Trauma-Penetrating o Solt Tissue Injury o
Bleeding/Hemorrhage
o
o OB/GYN Burns Environmental o Heat
o o
Cold
o Hazardous Materials Obvious Oeath
PAST MEDICAL HISTORY
o None o AlJergyto o Hypertension o Seizures o capo o Other (List)
Rate:
0
o Regular o Shallow o Labored
o Stroke o Diabetes o Cardiac o Asthma
o o o
Rate:
o Regular o Shallow o Labored
Current Medications (List)
Rate:
o Regular o Shallow o Labored
o o o o
Alert Voice Pain Unresp.
o o o o
Alert Voice Pain Unresp.
0 0
o o o
0 0
o o o
Normal Dilated Constricted Sluggish No-Reaction Normal Dilated Constricted Sluggish No-Reaction Normal Dilated Constricted Sluggish No-Reaction
0 0 0 0 0 0 0 0 0 0 0 0 0 0
o Unremarkable oCool o Pale oWarm o C~anotic o Moist OF ushed 00 o Jaundiced o Unremarkable o Pale oCool o Warm oC~anotic o Moist OF ushed 00 OJaundiced o Unremarkable OCool o Pale o Warm OC~anotic o Moist OF ushed 00 o Jaundiced
mmm DC
OU oP OS
DC
OU OP OS
DC
OU OP OS
-'------------------
--
o Moved to ambulance on stretcher / backboard o Moved to ambulance on stair chair o Walked to ambulance o Airway Cleared o Oral/Nasal Airway o Esophageal Obturator Airway / Esophageal Gastric Tube Airway (EOAlEGTA) o EndoTracheal Tube (EIT) r--r-I o OxygenAdministered@ L---.l..-J L.P.M., Method _ o Suction Used o Artificial Ventilation Method _ o C.P.R. in progress on arrival by: 0 Citizen 0 PD/FD/Other First Responder 0 Other ~ TimefrornArrest I I - r I o C.P.R. Started@ Time ~ ~ Until C.P.R. ~ l-...L...L-..J Minutes o EKG Monitored (Attach Tracing) [Rhythm(s) ]
D
0 Manual
AGENCY COPYIWHITE
0 Semi-automatic
o Medication Administered (Use Continuation Form) r--r-I o IV Established Fluid Cath. Gauge L---.l..-J o Mast Inflated @Time ) o Bleeding/Hemorrhage Controlled (Method Used: ) o Spinal Immobilization Neck and Back o Limb Immobilized by 0 Fixation OTraction o (Heat) Dr (Cold) Applied o Vomiting Induced @Time Method _ o Restraints Applied, Type _ o Baby Delivered @Time In County _ o Alive 0 Stillborn 0 Male 0 Female o Tran ported in Trendelenburg position o Transported in left lateral recumbent position o Transported with head elevated o Other
NON-HOSPITAL DISPOSITION CODES: NURSING HOME OTHER MEDICAL FACILITY RESIDENCE. ... TREATED BY THIS UNIT, TRANSPORTED BY ANOTHER UNIT REFUSED MEDICAL AID OR TRANSPORT CALL CANCELLED, STANDBY ONLY (NO PATIENT) NO PATIENT FOUND, OTHER.......
THE RULE OF NINES
\~ f ,
001 002 003
Estimation of Burned Body Surface (PERCENT)
G
8 [Front) , ,
i~
004 005 006 007 008 010
~ 18 [Back)A
) 91!
(',9
I
.
~,
l~
,j'
A18
18
l~
(
\
18 /
! ):
{) . .~.~.~~.~~. (j
; \ I
l14 \ 14 \
Hospital Receiving Agent
~
9\
IF~~tl.'~:
"'".
1
(
INFANT
ADULT
SIGNATURE
REFUSAL OF TREATMENT/TRANSPORTATION
Glasgow Coma Scale
NEGATIVA A RECIBIR TRATAMIENTOjSER TRASLADADO
Eye Opening
RELEASE
Th~i~
EXONERACION DE RESPONSABILIDADES Verbal Response
COMPLETE ON WHITE (AGENCY) COPY ONLY LLENE UNICAMENTE LA COPIA BLANCA (DE LA AGENCIAj I hereby refuse (treatment/transport to a hospital) and I acknowledge that such treatment/transportation was advised by the ambulance crew or physician I hereby release such persons from liability for respecting and following my express wishes.
Motor Response
Mediante la presente declaro que me niego a aceptar el tratamiento/traslado a un hospital y reconozco asimismo que el medico 0 el personal de la ambulan cia recomendaron ese tratamiento/traslado. Consiguientemente, eximo adichas personas de toda responsabilidad por haber respetado y cumplido mis deseos expresos.
To Pain None
2
Oriented
5
Confused
4
Patients Best Verbe Respopse
Inappropriate Words Incomprehensible Sounds
3
Arouse patient with vOice or painful stimulus.
None
1
Obeys Command Localizes Pam Withdraw (pain) Flexion (pain) Extension (pain)
6 5 4 3 2
None
1
Total GCS Score
Signed:
4 3
Spontaneous
Firma:
1
Patient's Best Motor Response Response to command or painful stimulus.
:3-15 ICD DIAGNOSTIC CODE
Witness: Testigo: - - - - -
•
INSURANCE 10#
CARRIER 1
WAS THIS A WORKERS' COMPENSATION INJURY:
2
DYES
D
NO
D
MEDICARE
2
D MEDICAID
3
D
BLUE CROSS
COMMERCIAL
4
D INSURANCE
INSURANCE CODE
PATIENT'S EMPLOYER:
D SELF PAY _
PHONE (
~
EMPLOYER'S ADDRESS
_
RESPONSIBLE PARTY ADDRESS
5
_ (=Zl"--P
_
PHONE ( RELATION
)__
Iii iii I
FOR BLS FR USE ONLY l----ri-r-i-'--i"'--iII iii
RUN NO.
AGENCY COOE
Name
Agency -+N:'.:.a:'.:.m.c::e Dispatch Information
I-:-c-c,-Address
MILEAGE - l END
CALL REC'D
I=~~~== -------+L~~~~-------------------------__ ~T-m~Al~:~~~~ A~R~~¥~~ I CHECK 0 Residence 0 Health Facility 0 farm 0 Indus. facility I --..".... .+::~ON.:7'E__=:=:=O':_Oth:-:::er:;;w~Or1<::--lOCr.---'O=--R-oa-'-dWa....:Y'---=O=-R-'-ec-'-re-'-at.c.iO".c.al_O=-o_In_er .............._ ............._-1 FROM SCENE ==*=:;=:;=:::; F CALL TYPE AS REC'O COMPLETE FOR TRANSFERS ONLY I -=,--,-,0=i 0 Emergency Transferred from ITIJ AT DESTIN BEGIN:
ENRDUTE
r-----------------------------------~C~I------------------------------r--+'-r+-r+~
r-
o r__
o Non-Emergency -l.--=O"-S""ta"'n""d--"BL-_ _-1
!-;;-:--;::-;:-.,.,.,...,===:-::-:"....,.,=,.,.,..,-
CARE IN PROGRESS ON ARRIVAL: o None 0 Citizen 0 PD/FD/Other First Res onder
o o
MVA () seat belt used ...... ) Struck b vehicle"'---
~1~iIPlllitPiijlllt!~j
l : : : __
1=:;=:::;:::=*=
0 No Previous PCR 0 Unknown if Previous PCR
0 Other EMS
Previous PCR Number
D- ITIIJJJ
0 Extrication required Seat belt used? minutes 0 Yes 0 No 0 Unknown
-='-=,iii
IN SERVICE
==::=~=:==
I IN QUARTERS
Se~\~elt 0 Crew Re orted B 0 Police
o Patient o Other
I
PRESENTING PROBLEM
o
Allergic Reaction 0 Syncope Airway Obstruction 0 Stroke/CVA Respiratory Arrest 0 Generallllness!Malaise Respiratory Distress 0 G~stro:lntestinal Distress Cardiac Related (Potential) 0 Diabetic Related (Potential) Cardiac Arrest 0 Pain ======
If more than one checked. circle primary
o
o
o
o
o
o o
o o
o
Unconscious/Unresp. 0 Shock Seizure 0 Head Injury Behavioral Disorder 0 Spinal Injury Substance Abuse (Potential) 0 Fracture/Dislocation Poisoning (Accidental) 0 Amputation
o Major Trauma
o Trauma-Blunl o Trauma-Penetrating o Solt Tissue Injury o
Bleeding/Hemorrhage
o
o OB/GYN Burns Environmental o Heat
o o
Cold
o Hazardous Materials Obvious Oeath
PAST MEDICAL HISTORY
o None o AlJergyto o Hypertension o Seizures o capo o Other (List)
Rate:
0
o Regular o Shallow o Labored
o Stroke o Diabetes o Cardiac o Asthma
o o o
Rate:
o Regular o Shallow o Labored
Current Medications (List)
Rate:
o Regular o Shallow o Labored
o o o o
Alert Voice Pain Unresp.
o o o o
Alert Voice Pain Unresp.
0 0
o o o
0 0
o o o
Normal Dilated Constricted Sluggish No-Reaction Normal Dilated Constricted Sluggish No-Reaction Normal Dilated Constricted Sluggish No-Reaction
0 0 0 0 0 0 0 0 0 0 0 0 0 0
o Unremarkable oCool o Pale oWarm o C~anotic o Moist OF ushed 00 o Jaundiced o Unremarkable o Pale oCool o Warm oC~anotic o Moist OF ushed 00 OJaundiced o Unremarkable OCool o Pale o Warm OC~anotic o Moist OF ushed 00 o Jaundiced
mmm DC
OU oP OS
DC
OU OP OS
DC
OU OP OS
-'------------------
--
o Moved to ambulance on stretcher / backboard o Moved to ambulance on stair chair o Walked to ambulance o Airway Cleared o Oral/Nasal Airway o Esophageal Obturator Airway / Esophageal Gastric Tube Airway (EOAlEGTA) o EndoTracheal Tube (EIT) r--r-I o OxygenAdministered@ L---.l..-J L.P.M., Method _ o Suction Used o Artificial Ventilation Method _ o C.P.R. in progress on arrival by: 0 Citizen 0 PD/FD/Other First Responder 0 Other ~ TimefrornArrest I I - r I o C.P.R. Started@ Time ~ ~ Until C.P.R. ~ l-...L...L-..J Minutes o EKG Monitored (Attach Tracing) [Rhythm(s) ]
D
0 Manual
AGENCY COPYIWHITE
0 Semi-automatic
o Medication Administered (Use Continuation Form) r--r-I o IV Established Fluid Cath. Gauge L---.l..-J o Mast Inflated @Time ) o Bleeding/Hemorrhage Controlled (Method Used: ) o Spinal Immobilization Neck and Back o Limb Immobilized by 0 Fixation OTraction o (Heat) Dr (Cold) Applied o Vomiting Induced @Time Method _ o Restraints Applied, Type _ o Baby Delivered @Time In County _ o Alive 0 Stillborn 0 Male 0 Female o Tran ported in Trendelenburg position o Transported in left lateral recumbent position o Transported with head elevated o Other
NON-HOSPITAL DISPOSITION CODES: NURSING HOME OTHER MEDICAL FACILITY RESIDENCE. ... TREATED BY THIS UNIT, TRANSPORTED BY ANOTHER UNIT REFUSED MEDICAL AID OR TRANSPORT CALL CANCELLED, STANDBY ONLY (NO PATIENT) NO PATIENT FOUND, OTHER.......
THE RULE OF NINES
\~ f ,
001 002 003
Estimation of Burned Body Surface (PERCENT)
G
8 [Front) , ,
i~
004 005 006 007 008 010
~ 18 [Back)A
) 91!
(',9
I
.
~,
l~
,j'
A18
18
l~
(
\
18 /
! ):
{) . .~.~.~~.~~. (j
; \ I
l14 \ 14 \
Hospital Receiving Agent
~
9\
IF~~tl.'~:
"'".
1
(
INFANT
ADULT
SIGNATURE
REFUSAL OF TREATMENT/TRANSPORTATION
Glasgow Coma Scale
NEGATIVA A RECIBIR TRATAMIENTOjSER TRASLADADO
Eye Opening
RELEASE
Th~i~
EXONERACION DE RESPONSABILIDADES Verbal Response
COMPLETE ON WHITE (AGENCY) COPY ONLY LLENE UNICAMENTE LA COPIA BLANCA (DE LA AGENCIAj I hereby refuse (treatment/transport to a hospital) and I acknowledge that such treatment/transportation was advised by the ambulance crew or physician I hereby release such persons from liability for respecting and following my express wishes.
Motor Response
Mediante la presente declaro que me niego a aceptar el tratamiento/traslado a un hospital y reconozco asimismo que el medico 0 el personal de la ambulan cia recomendaron ese tratamiento/traslado. Consiguientemente, eximo adichas personas de toda responsabilidad por haber respetado y cumplido mis deseos expresos.
To Pain None
2
Oriented
5
Confused
4
Patients Best Verbe Respopse
Inappropriate Words Incomprehensible Sounds
3
Arouse patient with vOice or painful stimulus.
None
1
Obeys Command Localizes Pam Withdraw (pain) Flexion (pain) Extension (pain)
6 5 4 3 2
None
1
Total GCS Score
Signed:
4 3
Spontaneous
Firma:
1
Patient's Best Motor Response Response to command or painful stimulus.
:3-15 ICD DIAGNOSTIC CODE
Witness: Testigo: - - - - -
•
INSURANCE 10#
CARRIER 1
WAS THIS A WORKERS' COMPENSATION INJURY:
2
DYES
D
NO
D
MEDICARE
2
D MEDICAID
3
D
BLUE CROSS
COMMERCIAL
4
D INSURANCE
INSURANCE CODE
PATIENT'S EMPLOYER:
D SELF PAY _
PHONE (
~
EMPLOYER'S ADDRESS
_
RESPONSIBLE PARTY ADDRESS
5
_ (=Zl"--P
_
PHONE ( RELATION
)__
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