Download - New Hampshire Pcr
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8/14/2019 New Hampshire Pcr
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DESTINATION
Initial VITAL SIGNALS: B/P: PULSE I RESP. I TEMP.PATIENT o ADMITTED ICU/CCU o ADMITTED MEDISURG 0 ADMITTEDTO SURGERY D DISCHARGED Other:DISPOSITION:
oDISCHARGED HOME D DOA 0 DIED D TRANSFERRED TO
SIGNATUREO f PERSON RECEIVING PATIENT: D Trauma Team Activated
077584RST RESPONSE I . S
First Responder Service Arrival Time Service #
ior Care by: 0 First Responder 0 MDIAN 0 Fire 0 Police 0 BystanderAid Given: 0 Moved Patient 0 CPR 0 O t h e ~
TYPE OF AMBULANCE RESPONSE
TO Scene: 0 Emergency o Mutual Aid o Non-Emergency 0 Cancelled En RouteFROM Scene: 0 Transport-TYPE OF CALL
o Allergic Reactiono Behavioralo Cardiovascularo Diabetico Gastrointestinalo HeaVHyperthermiao Hypothermia/Frostbiteo Neurologicalo OblGyno Poisoning/Overdoseo Respiratoryo Toxic Exposureo Traumao Urinary Tracto Vascularo OTHER:
o AIRWAY Openedo Manually Clearedo Nasopharyngealo Oropharyngealo EOA 0 successfulo ET 0 successfulo NTT 0 successfulo Suctiono Cricothyroid Needle Puncture
o OXYGEN Administeredo Cannula Umo Simple Mask Umo Non-rebreather um
o BREATHING Assistedo Bag Valve Masko Demand Valveo Pocket Mask
o BLEEDING Contronedo Bandage/Dressing Applied
o Intraosseous infusiono IV attempted 0 successfulMAST inflated: 0 Legs 0 Abdomen
ODOMETER
CARE GIVEN PATIENT
o Transfer o No Transport 0 Care RefusedMECHANISMOF INJURY SCENE
o Vehicle Type:
o Air Bag Inflatedo Restraint usedo Child restrainto Helmet used
o Drowning/Suffocationo Electricalo Fallo Fireo Organized Sports
o StablGunshoto TooVObject: Specify
o OTHER:
CARDIAC Care
o CPRo Gardioversion X _o Defibrillation X _o Monitoringo Pacingo Drug Administration
TRAUMAGare
o Extricationo Cervical Imm'JIJilizationo Short Boardo Long Boardo Bum Careo Chest Decompressiono Sling/Swatheo Splint, type:o Splint, traction
o OBIGYN Care/Childbirtho Restraint appliedo OTHER CARE:
MILEAGE
...,_IIIIiI-.LOADEDMILES
o Farmo Homeo Industrialo Loggingo Medical Facilityo Public BuildingIPlaceo Recreationalo Schoolo StreeVHighwayo OTHER:
o AT WORKo Hazardous Materialso Mass Casualty
ABDOMENBACK
HEAD
CHESTNECK I THROAT
FACE I EYE I EAR
C}C}Z Z
::::i 0 z-' ::::iuu i= C)I z 3: en zn
0 ::::> en z t:C) a: uu ent= ~ en
enz 0 ~ "- uu ~ (5 i=:: a: 0 z~ u z z 0 en CDCl. zw ::::> a: "- en ::::;::2: - ' - ' ::::> uu 0 ~ ; ( CO CO CO 0 -' z Cl.
UPPER ARM I SHOULDERLOWER ARMI ELBOWI HAND
UPPER LEG I HIPLOWER LEG I KNEE I FOOT
SIGNS and SYMPTOMS
o Altered Mental Status o Cold/Shivering o Respiratory Arreo Apparent Death o Dizziness/Fainting o Vision Impairedo Breathing Difficulty o Hot/Feverish D OTHER:
( 0 Cardiac Arrest o NauseaIVomiting
GLASGOW COMA SCALEEyeOpeningResponse
BestVerbalResponse
BestMotorResponse
Guarantor's Name
SPECIAL BILLING INSTRUCTIONS: (Social Security #. Other Insurance, etc.)
o Medicare D Medicaid 0 Workman's Compoo Private Insurance D Private No Insurance 0 VA D O
SPONTANEOUS 4
TO VOICE 3
TO PAIN 2
NONE 1
ORIENTED 5
CONFUSED 4
INAPPROPRIATE WORDS 3
INCOMPREHENSIBLE SOUNDS2
NONE 1
OBEYS COMMANDS 6
LOCALIZES PAIN 5
WITHDRAWS (PAIN) 4
FLEXION (PAIN) 3
EXTENSION (PAIN) 2
NONE 1
REVISED TRAUMA SCOGLASGOWCOMASCALE (GCS)(Total pointsfrom left)
SystolicBloodPressure
RespiratoryRate
13-15
9-12
6-8
4-5
3
> 89 mm HG
76-89 mm HG
50-75 mm HG
1-49 mm HG
No Pulse
10-29/min
> 29.min
6-9/min
1-5/rnin
None
Retationship
Pllone
State
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AV
- - l ._-- ' -_+-- : - : - : - - - 'p ' -U" ' - jAV
L - - l . - - - ' - - + - - : - : - : - - - ' p ' - = U + - - - - = O : : - : s : : : t : ; : r o : : n g ! L . . : O = _ - ' - w : . . : : e " " ' l _ - - - ' - - - + - - - . . : O = _ . . : : L a : : : b o = r e d : : : . - : : O : AV
LEAVE SCENE AT HOSPITAL IN SERVICE
ME (24 Hour) L.O.C. PULSE BP RESPIRATIONS LUNG SOUNDS PUPILS SKIN TEMPERATUREAV o Regular 0 Irreg 0 Normal 0 Abnormal L R SOUNDS L R D Normal o Normal
Reactive 0 Cyanolic:=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--lClear D Warm/Hot0 Regular 0 Irreg 0 Normal 0 Abnormal Absent Unreactive D M t
Constricted 0 OIS D CooVCoidStridor Flushed;0 Regular 0 Irreg 0 Normal 0 Abnormal Rales
Dilated D.p.ale C/Fo SIron 0 Wea 0 Labored 0 Shallow Rhonchi o Unequal o Regular 0 Irreg 0 Normal 0 Abnormal Wheezes o D1SCOr1Jugate. . L _mm R_mm 1 3 5 7o Stron 0 Wea 0 Labored 0 ShallowTime Treatment Results/Observations NH ALS#
Verbal Order ONTROL Physician:EDICAL Name of
Standing Order
Signature, Primary Care AttendentAMBULANCE CREW
and LICENSE #:
Original - Service WHITE COPY - HOSPITAL Yellow Copy - EMS Green Copy - EMS Hosp Coor
miEINEW HAMPSHIRE EMS Patient Record
I 1---.LL.BmI / /NH Lie # Mo. Day
oYear
584I
Call #~ Medical Facility or Street
ICityfTown State
Address
Last
IFirst M.I. Phone #
CityfTown State ZIP
_-- ' - - - ' ---lEII'-----_---'--'D=--;;F, - - D = - - - ' M - ' - - _ ~ , . . . , . . , . . . - . . L . . . - - - - = 1 :--,--2,----;;3,--,---_4
: ; -_-- ; : -_Mo. Day Year Sex Weight Patient Status , -_- ' - ' . : : : : : .=. :=;
l - : : - : - : c - - - - : - : - - - - - - - - - __ --=----::- c . = = - - - . . : . _ - - J . .Relationship Phone #
HIEF COMPLAINT
PAST MEDICAL HISTORYAllergies
Meds Rx:
Pertinent MediSurg. Hx:
Medical I.D. lor:
Patient's MD
EMS RESPONSE TIMES
IT I I J IT I I J IT I I JDISPATCH RESPONDING ARRIVE SCE
ITI I J ITI I J ITI I J
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