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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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_ _ _ _

- - - - - - - - -PU

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

9