Prepared by the Division of Emergency Medical Services

ALSBasic Training Course(Complete Dataset)

Medical Incident Report Form

Education Module for 2008

Prepared by the Division of Emergency Medical Services

Education Module Goals

• Train new EMS personnel

• Provide a review for experienced EMS personnel

Education Module Contents

• Basic information & general

instructions

• Cardiac arrest highlight

• 2008 MIRF dataset

Basic Information & General Instructions

Why the MIRF is Important

• Medical– The entire MIRF (both electronic form and

paper ‘short form’) is part of the patient’s medical file.

– The MIRF transfers information between patient care providers.

• Legal– Confidentiality– Patient Refusal– MIRF Signature

Why is the MIRF is Important (continued)

• Quality Review• Planning/Funding

– Medic unit placement, levy funding• Research

– Resuscitation Outcome Consortium (ROC)

– Supporting Public Health with Emergency Responders (SPHERE)

Components of a Good Report

• Completeness– All available information regarding

the incident or patient care should be recorded.

• Accuracy– Describe exactly what happened.

• Correct spelling• Legibility (on paper forms)

Components of a Good Report

(continued)•Narrative: use S.O.A.P

format:– Subjective– Objective– Assessment– Plan

Basic Instructions• An electronic record is created by CAD/Dispatch

for every call/incident.

• When completing the paper (short) form in the field, use a ball point pen & press hard enough to mark through all copies.

• Complete the electronic record verifying that the CAD information is accurate.

• Refer to your agency protocols regarding exceptions to completing the paper form.

MIRF Pages

• Agency copy

• EMS copy

• Medical Review copy

• Patient copy

• Cardiac worksheet (Short Form Only): A reminder sheet to assist EMS Personnel in collecting CPR data in the field. May be discarded.

Completing the MIRF

The person who provided primary care should:

• Sign your name• Print your name• Write your EMS number

• Follow the instructions on the back of the MIRF.

• Fill in patient’s name, and the date.• Read the statement slowly & clearly to the

patient. Ask if they understand what it says.

• Have the patient/guardian sign in the appropriate spots.

• If patient/guardian refuses or you are unable to obtain a signature, make a note to that effect.

• Obtain a signature from a witness and note their EMS agency affiliation or address.

Patient Refusal

Cardiac Arrest Highlight

Cardiac Arrest HighlightResearch findings from cardiac arrest data have

improved patient care and saved lives.

When CPR is performed by EMS personnel, fill out the ENTIRE CPR section including:

• Was cardiac arrest witnessed?• Did patient arrest after EMS

arrival?• Who initiated CPR?• Was AED/PAD used?• What was the initial arrest

rhythm?

•Did paramedics cease

resuscitation upon arrival?• Estimated elapsed times• Time of return of

spontaneous circulation• What was the patient

outcome?

Cardiac Arrest Highlight (cont.)

• Cardiac Arrest WitnessedIf someone directly saw or heard the patient

collapse, then the arrest is considered witnessed

and you should mark “Yes”. If the patient’s

collapse was not seen or heard, but found after

an unknown length of time, it is considered

unwitnessed and you should mark “No”.

• Arrest After Arrival of EMS Personnel

Did the arrest occur after the arrival of

emergency personnel?

Cardiac Arrest Highlight (cont.)

• CPR Initiated ByIndicate the first person to begin CPR:

1 First Responder/Police

2 Fire Department (BLS)

3 Paramedic (ALS)

4 Ambulance

5 MD/RN

6 Citizen with Dispatch Assistance

7 Citizen without Dispatch Assistance

8 CPR Not Attempted

Cardiac Arrest Highlight (cont.)

• AED/PAD UsedWas AED/PAD used?

1 Citizen – No Shock

2 Citizen – Shock

3 First Responder/Police – Shock

4 First responder/Police – No Shock

Cardiac Arrest Highlight (cont.)

• Initial ECG RhythmFirst observed cardiac rhythm by paramedic:

01 Sinus Rhythm

02 Asystole

03 PEA

04 Other

05 Atrial Fibrillation

11 Ventricular Fibrillation

12 Ventricular Tachycardia

U0 Unknown

Cardiac Arrest Highlight (cont.)

• Paramedics Cease Resuscitation On

ArrivalIndicate if resuscitation was ceased by paramedics within

the first few minutes of arrival on scene due to DNR orders,

compelling reasons, or conditions not compatible with life.

• Estimated Elapsed Time (minutes) from

Collapse to Call

For witnessed arrest only; the estimated number of

minutes between collapse of the patient and the

reporting party reaching the correct agency by phone. If

the collapse was unwitnessed or you cannot estimate the

time, do not enter anything.

Cardiac Arrest Highlight (cont.)

• Estimated Time (minutes) from

Collapse to CPRFor witnessed arrests only, the estimated number of

minutes from the patient’s collapse to the time CPR was

initiated.

• Time Return of Spontaneous

Circulation

Time of the return of any palpable pulse. A palpable pulse

would be one detectable by manual palpation of a major

artery, usually the carotid.

Cardiac Arrest Highlight (cont.)

• Patient OutcomeComplete for all cardiac arrest patients.

01 DOA

02 Expired at Scene (including during

transport)

03 Admitted to ER

04 Expired at ER

05 Admitted to Hospital

06 Unknown

Cardiac Arrest Highlight (cont.)

• When CPR is performed…

– Mail the red copy of the MIRF and a printout of your electronic record to the EMS Division within 4 days of the event.

2008 MIRF Dataset

•Incident Data (in alphabetical order)

•Patient Data (in alphabetical order)

Incident Data

• Action Taken• Agency Incident Number• Aid Type

• Date/Time Arrived on Scene• Date/Time Dispatch Notified• Date/Time In Service• Date/Time Last Response Unit Leave

Scene• Date/Time Primary PSAP Notified• Date/Time Unit Notified by Dispatch• Date/Time Unit Responded

Incident Data (Cont.)

• First Agency on Scene ID• First EMS Reporting Agency on

Scene• First Unit on Scene• Geocode

Incident Data (cont.)

• Incident Address• Incident City• Incident County• Incident State• Incident Type (NFIRS)• Incident Zip Code

Incident Data (cont.)

• Initial (Incident) Dispatch Code (IDC)

The IDC is received from the dispatch center that dispatched your unit. If no IDC is given or obtainable, leave blank.

• Location Type• Outside Agency Incident Number• Property Use (NFIRS)

Incident Data (cont.)

• Reporting Agency Number• Reporting Unit ID Number• Responding from Quarters• Responding in Fire District Code

Incident Data (cont.)

• Response Delay TypeThe response delays, if any, of the unit associated with the patient encounter.

Incident Data (cont.)

130 Directions140 Diversion150 None 160 Safety170 Traffic180 Vehicle Failure125 Crowd

135 Distance145 HazMat155 Other165 Staff Delay175 Vehicle Crash185 Weather

Incident Data (cont.)

• Response Mode• Treatment Crew Member Name

         

Patient Data

1 Exam Only: Examined but no treatment performed2 Exam & Assist: Treatment/medical assistance given3 No Exam: Did not examine patient4 Patient Refused Exam, Treatment, and/or Transport5 Service Aid/Patient Assist: Patient needed help but did

not need exam

• Action Taken

• Allergies• Blunt/Penetrating Injury – Blunt or

Both• Blunt/Penetrating Injury –

Penetrating to Chest/Abdomen• Blunt/Penetrating Injury –

Penetrating - Other

Patient Data (Cont.)

• Date/Time Arrived at Patient’s Side• Date/Time Arrived at Treatment

Facility or Transfer Point• Date/Time Extrication is Completed• Date/Time Patient Left Scene• EMS ID Number of Person

Completing Form

Patient Data (Cont.)

• Flow Chart

Patient Data (Cont.)

TimeBlood PressurePulse RateRespiratory RateECG Rhythm*Oxygen*Pulse OximetryGlucometryIV fluids (liters)DC Shock/AED UsedMedications

*Revised data elements (see next slide)

• Flow Chart (cont.)

Patient Data (Cont.)

ECG Rhythm* 01 Sinus Rhythm 02 Asystole 03 PEA 04 Other 05 Atrial Fibrillation 11 Ventricular Fibrillation 12 Ventricular Tachycardia U0 Unknown

• Flow Chart (cont.)

Patient Data (Cont.)

Oxygen Mechanism*1 Non-rebreather2 Nasal Cannula3 Bag Valve Mask4 Blow-By5 Other (see Narrative)6 BVM + ITD

The notes section of the flow chart can be used for notes or for extended flow chart information

• Glasgow Coma Eye Opening Component

• Glasgow Coma Motor Response• Glasgow Coma Verbal Response• Glasgow Coma Score (GCS)

Patient Data (Cont.)

• Highest Level of Care Provided• Mass Casualty Incident

Indicates if existing EMS resources were overwhelmed and event was considered an MCI.

• Medical Facility Contacted Name• Medical Person Contacted Name• MIRF Number Indicates pre-printed unique number located on MIRF

Patient Data (Cont.)

Patient Data (Cont.)

• Narrative

Use the S.O.A.P. format:SubjectiveObjectiveAssessmentPlan

• Onset of Symptoms• Patient Age, Units• Patient Date of Birth• Patient Street Address, City, County,

State, Phone• Patient First Name, Middle Initial, Last

Name• Patient Gender• Patient Health Care Provider, Phone

Patient Data (Cont.)

• Patient Nearest Relative Name, Phone, Relationship

• Patient Mechanism Code• Patient Medications Taken at Home, ID• Patient Suspected Alcohol or Drug Use• Patient Type Code

Patient Data (Cont.)

• Procedures

Check all boxes for procedures performed.

For procedures 12-31 only: write the procedure number and the EMS number of the person who performed the procedure

Procedure: 36 – 12 Lead

Procedure: 37 – End Tidal CO2/Capnography

• Treatment Crew Member Number for Procedure

Patient Data (Cont.)

• Safety Equipment• Signature of Person Completing Form• Transport Agency Number• Transport Delay Type

The transport delays, if any, of the unit associated with the patient encounter

• Transport Destination• Transport Unit Number

Patient Data (Cont.)

• Trauma Band Number• Trauma Criteria Met?• Trauma Triage (TTC)

Patient Data (Cont.)

Prepared by the Division of Emergency Medical Services

Medical Incident Report FormEducation Module for 2008

Prepared by the Division of Emergency Medical Services

THE END

ALS