SOUTHERN FOX VALLEY



A. PURPOSE:

To comply with Article VI, Rule 6.01, Data Collection Plans, of Pre-hospital Medical Services Act: Chapter 1ll 1/2, Para, 410 et seg. Illinois Revised Statutes, as amended by Public Act 81-922.

B. POLICY:

1. The Southern Fox Valley EMS System will collect data according to specifications set forth in the Emergency Medical Data Collection System record keeping system.

2. Data will be collected and maintained by the EMS Medical Director or his designee in the form of written EMS record copies filed with the SFVEMS system office and/or Computerized.

3. A copy of the SFVEMS system record shall be filed with the receiving hospital on each patient transported to the facility for inclusion in the patient’s permanent medical record.

4. All non-transport vehicle providers shall document all medical care provided and shall submit the documentation to the EMS system within 24 hours. The Resource Hospital shall review all medical care provided by non-transport vehicles and shall provide a report to the Department upon request.

5. All refusals and or other paperwork pertaining to the incident and or patient shall be scanned and uploaded /attached to the computer report for that incident.

6. The ambulance provider shall submit the run report data to the Resource Hospital. Each Resource hospital shall submit a data report to IDPH on March 1, June 1, September 1, and December 1 of each year covering run report data from the preceding quarter.

C. PROCEDURE:

Listed below is the proper procedure for filling out the SFVEMS Patient Care Report in the ESO Solutions reporting software. This report should be completed prior to leaving the receiving facility and within 24 hours of a non transport incident.

SOUTHERN FOX VALLEY EMS SYSTEM

ESO SOLUTIONS PATIENT CARE REPORT

DATA ENTRY DICTIONARY

FINISHING A REPORT

WHEN YOU ARE DONE WITH YOUR REPORT YOU NEED TO VALIDATE AND LOCK THE REPORT.

Validating: When you feel you are done with your report hit the validate button at the top of the page. You will get a message that says validation is complete, you can then lock the report by hitting the lock button (next to validate). If the report is not complete, you will get a list of items that need to be completed to validate the report. Click on the item and it will take you to the area that needs to be completed. Once this is done and validation is complete, hit the lock button.

Locking: Once the report is complete, hit the lock button, the validation process will run and if the report is not validated it will give you the message of what needs to be completed before the report can be locked.

NOTE: If you have multiple patients it will default to patient 1 in the validation process.

Print: select the print button on the home page, once that page comes up, select the pdf view button on the top of the page and then select print.

Fax: On the home page, select the fax button; a fax number will appear and you would need to okay the fax process. This function is to be used when there is no printer attached to the computer you are using. The fax numbers can be used at any time and are pre programmed for the destination you chose in the patient disposition area.

Email: On the home page, select the email button, the email address is pre populated to a specific email address of the receiving facility. Example: Rush Copley – Jack Taxis

Cancel / Continue

When you attempt to navigate from a page that you have made changes to, you will see a box that states the following:

Are you sure you want to navigate away from this page?

Any unsaved changes will be lost.

Press OK to continue – you will lose your data

Press cancel to stay on the current page

INCIDENT DETAILS PAGE:

1. CALL DATE

2. INCIDENT NUMBER – The incident number assigned by the your Dispatch System

INCIDENT DETAILS

3. RUN TYPE - The type of service or category of service requested of the EMS service responding to the specific EMS incident

a. 911 call

b. Emergency Transfer

c. Non Emergency Transfer

d. Standby

e. Mutual Aid

f. Intercept

4. MUTUAL AID – select a reason for your mutual aid response

a. Additional Ambulances Needed

b. Disaster response

c. Other

d. Rendezvous for equipment failure

e. Rendezvous for level of care

f. Rendezvous for patient pick up

g. unknown

5. PRIORITY – Indication whether or not lights and/or sirens were used on the vehicle on the way to the scene

a. No lights / sirens

b. Lights / sirens

c. Lights / sirens downgraded

d. Lights / sirens upgraded

6. LEAD MEDIC – primary patient care giver

7. DRIVER – person who drives ambulance from scene to destination

8. MEDIC 3 – secondary patient care giver

9. MEDIC 4 – additional patient care giver

10. MEDIC UNIT / DISTRICT – select from a pre populated drop down box

11. VEHICLE – select from a specific pre populated drop down box

INCIDENT LOCATION

12. LOCATION TYPE – The kind of location where the incident happened

a. Home

b. Street or Highway

c. Doctor’s office

d. Nursing home

e. Assisted Living Center

f. Hospital E. R.

g. Hospital - other or unspecified location

h. Dialysis

i. EMS provider

j. Other specified space

k. Rehabilitation Center

13. LOCATION NAME – fill in specific information for Location Type

14. LOCATION ADDRESS – The street address (or best approximation) where the patient was found, or, if no patient, the address to which the unit responded

15. ZIP CODE – the ZIP code of the incident location

16. ZONE – specific to responding unit / agency

17. CITY - The city or township (if applicable) where the patient was found or to which the unit responded (or best approximation)

18. COUNTY – The county or parish where the patient was found or to which the unit responded ( or best approximation)

19. STATE – The state, territory or province where the patient was found or to which the unit responded (or best approximation)

INCIDENT TIMES / MILEAGE – the program automatically defaults to the current days date. If your incident spans two different dates you need to change the date for your entry.

20. CALL RECEIVED – The time the phone rings (911 call to public safety answering point or other designated entity) requesting EMS services

21. CALL DISPATCHED – The time the responding unit was notified by dispatch

22. ENROUTE - The time the unit responded: that is, time the vehicle started moving

23. ON SCENE – The time the responding unit arrived on the scene: that is the time the vehicle stopped moving

24. AT PATIENT – The time the responding unit arrived at the patient’s side

25. DEPART SCENE - The time the responding unit left the scene (vehicle started moving)

26. AT DESTINATION – The time the responding unit arrived with the patient at the destination or transfer point

27. INCIDENT CLOSE – The time the unit was back in service and available for response (finished the call, but not necessarily back in home location) (this will be the time you leave the hospital per SFVEMSS). If the report is completed at the hospital, the time you finish the report will be your incident close time. If you get another call while typing your report you would use the time you left the hospital for your incident closed time, when you finish your report. For a non transport, the incident closed time would be the time that you left the scene

28. ODOMETER READING – this is a mandatory field for some departments

a. START – The mileage (odometer reading ) of the vehicle at the beginning of the call (when the wheels begin moving)

b. AT SCENE – The mileage (odometer reading) of the vehicle when it arrives at the patient

c. AT DESTINATION – The mileage (odometer reading) of the vehicle when it arrives at the patient’s destination

d. END – The ending mileage (odometer reading) of the vehicle (at time back in service)

e. LOADED MILES

f. TOTAL – total number of miles for incident

29. AEROMEDICAL SERVICE CONTACTED – check box if helicopter activated (to be filled in anytime helicopter is activated)

a. CONTACT TIME – time dispatch / scene talk to helicopter service requesting air response

b. AT SCENE – time which helicopter / aeromedical unit arrives on the scene

c. DEPART SCENE – time which helicopter / aeromedical unit departs the scene

30. DELAYED RESPONSE – The response delays, if any, of the unit associated with the patient encounter

a. Traffic

b. Weather

c. Vehicle failure

d. Vehicle crash

e. Distance

f. Directions

g. Crowd

h. Diversion

i. Other

j. Staging

INCIDENT OUTCOME

31. DISPOSITION – Type of disposition treatment and/or transport of the patient

A. TRANSPORT CODE 1 (Non-Emergency)

B. TRANSPORT CODE 3 (Emergency)

C. TREAT NO TRANSPORT – (Assessed/Treated/ No Transport)

D. NO TREAT NO TRANSPORT – Pt Refused ALL Care and Assessment

E. NO PATIENT FOUND – NO one PHYSICALLY there!

F. FALSE ALARM (NO INCIDENT OCCURRED) (Accidental tone out)

G. CALL CANCELLED – Other agency cancelled you enroute

H. DEAD ON SCENE NO TRANSPORT

I. DEAD ON SCENE TRANSPORT

J. PATIENT CARE TRANSFERRED – BLS to ALS, BLS/ALS to Aeromedical

K. DISREGARDED ENROUTE

32. Refusal Reason – if C or D in the above list are entered, you then need to select a Refusal Reason from the following drop down menu

a. Against medical advice

b. Patient to seek further care in POV

c. Patient does not feel injury/illness requires ambulance

d. Patient in custody of law enforcement

e. Other

33. Transport due to - select from the following drop down menu – reason patient transported to the receiving facility.

a. Patient

b. Family

c. Protocol

d. Trauma triage

e. Distance – closest facility

f. Physician

g. Diversion - when one hospital sends you to another facility (hospital on bypass)

h. Other

34. Diverted from - if you choose item g in the transport due to box you will need to select a facility from the drop down box, to indicate who diverted the unit.

35. Transport to – drop down pre populated box

36. Requested by – who requested the ambulance for this incident

a. Patient

b. Family

c. Bystander

d. Physician

e. NH staff

f. Law enforcement

g. Other

37. Treatment Level – level of care that patient received

a. BLS

b. ALS

c. Critical Care

DESTINATION INFORMATION

38. Critical Trauma Criteria Met: If your selection in Destination Type (35) is a Hospital ER you will need to fill in this area

a. Level I

b. Level II

c. Level III

d. No

39. Trauma System Activated

a. Yes

b. No

c. N/A

d. Unknown

PATIENT INFORMATION PAGE

PATIENT DATA

1. LAST NAME – The patient’s last (family) name

2. FIRST NAME – Patient’s first (given) name

3. MIDDLE INITIAL / NAME – The patient’s middle name, if any

4. SSN – patient’s social security number

5. DOB – patient’s date of birth (calendar picture will give you a date selector)

6. AGE - will automatically populate if you put in DOB

7. GENDER – Select Male or Female

8. RACE / ETHNICITY – The patient’s race as defined by the OMB (US Office of Management and Budget)

a. American Indian/Alaskan Native

b. Asian/ Pacific Islander

c. Black

d. Hispanic

e. Other

f. Unknown

g. White / non Hispanic

9. Copy Incident Address – check this box if incident is at patients home address this will then populate the patient information address area

10. COUNTRY – Patient’s home Country – drop down menu

11. ADDRESS – The patient’s home mailing or street address

12. ZIP CODE - The patient’s home ZIP Code of residence

13. CITY – The patient’s home city or township or residence

The looking glass next to boxes 12 and 13 will assist you in obtaining proper zip code for a city. If you look up one of the above items - selecting an item will populate the other box

14. COUNTY – The patient’s home county or parish or residence -

This box will also populate when selecting box 12 or 13

15. STATE – The patient’s home state, territory or province or District of Columbia, where patient resides

16. TELEPHONE – The patient’s home or primary telephone number

17. DRIVER’S LICENSE – The patient’s driver’s license number

18. DL STATE - The state that issued the patient’s driver’s license

ONCE THIS SECTION IS COMPLETE HIT THE SAVE BUTTON ON THE SCREEN

Frequently seen patients can be selected if you have the patients name and social security number. This will populate the address, billing and past medical history / medication fields for you. This information will need to be verified to be correct before saving. Patients are saved for 6 months.

After this information is saved, you can add any additional patients to the incident.

Select the “Add New Patient” button (next to the SAVE button) and a new patient information screen will come up. The incident information page will be added to this patients report. You may need to go back and change the incident outcome information.

To navigate between patients you go to the top of the page and select patients by using the forward and back arrows. If you have more than one ambulance on the scene they will each need to fill out information for their patients.

MED HX /ALLERGIES/MEDS

19. MED HX/ALLERGIES/ MEDS – select one area at a time from the drop down menu of the three items below, you will then go to the TYPE area (20) for specific items

a. Past History

b. Allergy

c. Present Medication

When selecting the following items, hit add after each entry and SAVE when you are done adding information.

20. TYPE – gives further information for each of the drop down boxes of item 19

Past History

a. Denies

b. Other

c. Unknown

d. Angina

e. Arrhythmias

f. Asthma

g. Behavioral/psych disorder

h. Cancer

i. Cardiac

j. Cardiac arrest

k. CHF

l. COPD

m. Coronary Artery Disease

n. Dementia

o. Epilepsy

p. Diabetes

q. Gastro Intestinal problems

r. Hypertension

s. Infectious disease

t. Myocardial Infarction

u. Pacemaker / AICD

v. Pregnancy/OB Delivery/Complications

w. Renal Failure

x. Seizures

y. Smoking

z. Stroke/CVA

aa. Substance Abuse

ab. Syncope

Allergy

a. NDKA

b. Denies

c. Other

d. Acetaminophen

e. Aspirin

f. Benzodiazepines

g. Chemical

h. Codeine

i. Food Allergy

Present Medication

a. Denies

b. Prescription

c. Non prescription

d. Unknown

e. List of common medications to select from

j. Insect Sting

k. Sulfonamides

l. Latex

m. Penicillin

21. MED/COMMENTS – enter any comments pertinent to patient care or history

You can enter Prescription in the previous area and then write out the list in this section instead of selecting individual medications

Select ADD as you are entering information, then hit SAVE to save all the entries

PERSONAL ITEMS

This section allows you to document the disposition of the patient’s personal items

22. PERSONAL ITEMS – a drop down lists of the patient’s personal items

a. Cell phone / pager

b. Jewelry

c. Keys

d. Medications

e. Other

f. Purse / wallet

g. Watch

23. GIVEN TO – enter who items were given to by name or location

24. NOTES / OTHER – any notes about personal items that are pertinent

SAVE THIS INFORMATION

VITAL SIGNS PAGE

1. VITAL SIGNS – Go thru these steps for each set of vitals that are recorded for the patient

a. Time / Date - time and date vitals were recorded

b. AVPU

Alert

Voice

Pain

Unconscious

c. Blood Pressure

Systolic

Diastolic

Method

Manual cuff

Automatic cuff

Palpated

d. Pulse

Rate enter number

Rhythm

Regular

Irregular

Absent

Paced

Strength

Strong

Weak

Bounding

Thready

Absent

e. Respiration

Rate enter number

Rhythm

Regular

Irregular

Ventilated

Assisted

Quality

Non-labored

Labored

Shallow

Absent

Ventilated

Assisted

f. Pulse Oximetry – enter the SP02 value Check whether recorded on room air or while patient is on oxygen

g. End Tidal CO2 - enter EtCO2 value

GLASCOW COMA SCORE

EYES – open to the following stimuli

a. 4 – spontaneous

b. 3 – to voice

c. 2 – to pain

d. 1 – none

VERBAL – responds in one of the following verbal means

a. 5 – oriented (smiles / babbles)

b. 4 – confused (irritable/non consolable)

c. 3 – inappropriate words (cries/screams with pain)

d. 2 – incomprehensible sounds (grunts/moans with pain)

e. 1 – none

MOTOR – responds with one of the following motor actions

a. 6 – obeys instructions (appropriate for age)

b. 5 – localizes to pain (withdraws to touch)

c. 4 – withdraws from pain (withdraws from painful stimuli)

d. 3 – abnormal flexion (decorticate posturing)

e. 2 – abnormal extension (decerebrate posturing)

f. 1 – none

Once this area is completed the program will automatically calculate the GCS and the Revised Trauma Score.

REVISED TRAUMA SCORE

This will automatically be calculated once you fill in the Glascow Coma Score area

ECG 3 LEAD RHYTHM

a. Agonal

b. Artifact

c. Asystole

d. Atrial fibrillation/flutter

e. AV Block – 1st degree

f. AV Block – 2nd degree type 1

g. AV Block – 2nd degree type 2

h. AV Block – 3rd degree

i. Junctional

j. Normal Sinus Rhythm

k. Paced

l. PEA

m. Sinus Arrhythmia

n. Sinus Bradycardia

o. Sinus Tachycardia

p. Supraventricular Tachycardia

q. Torsades De Points

r. Ventricular Tachycardia

s. Ventricular Fibrillation

t. Other

12 LEAD INTERPRETATION – Enter YOUR interpretation of the 12 lead

SUSPECTED MI – check this box for a suspected MI

BLOOD GLUCOSE – enter the value

PAIN SCALE (0-10) – select the appropriate or voiced value

a. 0-1 no pain

b. 2-3 mild pain

c. 4-5 moderate pain

d. 6-7 bad pain

e. 8-9 very bad pain

f. 10 unbearable pain

TEMPERATURE – enter the patient’s temperature in F or C

Hit the SAVE button and then enter additional sets of vital signs – you must enter SAVE between each set of vitals

FLOWCHART PAGE – This page contains documentation of treatments that the patient received.

1. TREATMENT TYPE – Select one of these choices and continue the following selections

a. Airway – ALS

b. Airway – BLS

c. Defib/Cardio/Pace

d. IV Therapy

e. Medication

f. Splint/Immob/Bandage

g. Critical Care

2. DATE

3. TIME

4. INTERVENTION

A. Airway – ALS

a. Combitube

b. King Airway

c. Laryngeal Mask Airway

d. Nasogastric Tube

e. Nasotracheal Intubation

f. Needle Cricothyroidotomy

g. Orogastric Tube

h. Orotracheal intubation

i. Pleural Decompression

j. Rapid Sequence Intubation (drug assisted intubation)

k. Retrograde Intubation

l. Surgical Cricothyroidotomy

m. Ventilator

B. Airway – BLS

a. CPAP

b. NPA – nasopharyngeal airway

c. OPA – oropharyngeal airway

d. Oxygen

1. NC – nasal cannula

2. NRB – non rebreather mask

3. BVM – bag valve mask

4. Pedi NC

5. Blow by

6. SFM – simple face mask

7. Venture

e. Suction

Once you select any airway intervention an Airway Complications box will pop up you then need to check one of the following if had any problems securing the airway

Gag reflex

Blood/vomit

Clenched teeth

Unable to visualize

Anatomy

Once you enter your airway intervention you will need to fill in the following information

Size

Placed at ___ cm

Successful yes / no

Provider – drop down box of crew members on incident

Oxygen – will ask you to fill in Flow Rate and Provider

C. Defib/Cardio/Pace

a. AED / Defib

b. Cardiovert

c. Manual Defib

d. Pacing

e. CPR

f. Resqpod

Once you select one of the procedures listed above, you will be asked to fill in the following:

Energy Type

Paced Rate – beats per minute

Capture Yes No

Provider

D. IV THERAPY

a. Blood draw

b. IV w /LR (lactated ringers)

c. LR bolus

d. IV w/ NS (normal saline)

e. NS bolus

f. Saline Lock

g. IV w/D5W

h. Central line

i. IV Monitoring

j. Intraosseous

k. EZ-IO (adult)

l. EZ-IO (pedi)

Once an IV Therapy intervention is selected you will need to fill in the following

SIZE

a. 14G

b. 16G

c. 18G

d. 20G

e. 22G

f. 24G

g. Double lumen

h. Single lumen

i. Triple lumen

SITE

a. L dorsal hand

b. R dorsal hand

c. L forearm

d. R forearm

e. Left AC

f. Right AC

g. Left External Jugular

h. Right External Jugular

i. Left lower extremity

j. Right Lower extremity

k. Left Tibia IO

l. Right Tibia IO

m. Sternal IO

n. Scalp

o. Other

p. Subclavian

q. Umbilical

r. Left subclavian

s. Right subclavian

t. Right tibia

u. Left tibia

v. Right humerus

w. Left humerus

You will also need to fill in the following boxes regarding the IV Therapy intervention

Total Fluid Infused

Successful yes no

Provider

E. MEDICATION

DATE

TIME

INTERVENTION

DROP DOWN LIST OF DRUGS

DOSE

MEASURE – This box will change to appropriate measure when you select a drug from the drop down list

1. Grams

2. Inches

3. IU

4. mEq

5. ml

6. units

7. self

8. sprays

9. mcg/min

10. mg/kg

ROUTE

1. Intravenous

2. Intramuscular

3. Intraosseous

PT. RESPONSE

1. Unchanged

2. Improved

3. Worse

4. Not applicable

Provider – who performed the intervention

After each intervention entry you need to click on the ADD button

When you are done entering all your interventions, you need to click on the SAVE button to make your entries permanent.

FIRST RESPONDER AID TYPE – Any care done for the patient prior to your arrival needs to be documented in this section This section can also be used when two separate departments respond to an incident – Dept. A responds with an engine and starts treatment, Dept. B responds with an ambulance and transport. Documentation of Dept. A’s care would go in this section.

A. Aid Prior to Arrival – By

a. First Responder

b. Law Enforcement

c. Nursing Home Staff

d. Physician on Scene

e. Healthcare Provider on Scene

f. Bystander

g. Not applicable

h. Other

i. Unknown

B.

C. Aid Prior to Arrival – Type

a. AED only

b. Bandaging

c. Bleeding Control

d. C-collar

e. CID – Cervical Immobilization Device

f. CPR

g. CPR and AED

h. MAST / PASG

i. Medication

j. NPA – nasopharyngeal airway

k. OPA – oropharyngeal airway

l. Other

m. Oxygen via BVM

n. Oxygen via NC

o. Oxygen via NRB

p. Spinal Immobilization

q. Splinting

r. Suction

s. Traction Splint

t. Ventilatory Support

D. Patient Response

a. Unchanged

b. Improved

c. Worse

d. Not known

e. Not applicable

E. Comments – you will need to enter any medications given in this box or any other pertinent information regarding care prior to your arrival

SAVE your entries

ASSESSMENT PAGE

ASSESSMENT DETAILS BOX - This box will be populated after you go thru the selection process of the remainder of the screen.

NOTE: IF “NO ABNORMALITIES” IS SELECTED YOU ARE SAYING THAT ALL LISTED ABNORMALITIES HAVE BEEN ASSESSED AND FOUND NOT TO BE PRESENT

**The program defaults to Not Assessed. **

If no abnormalities or not assessed is checked then you do not need to check any other box – this applies to all of the assessment sections

MENTAL STATUS

No Abnormalities

Not Assessed

Combative

Confused

Hallucinations

Unresponsive other

NOT Oriented to - (check box) person place time event

Comments

ANATOMICAL PICTURE – Click to enlarge the anatomical picture – Anterior or Posterior

You can navigate between anterior and posterior view once you enlarge the picture

Click on the injury type – take your mouse and click on the anatomical part that has the injury a red box with the injury listed will appear on the picture.

To delete or change an injury location, Click on the red injury indicator to change it to blue – this puts you into edit mode. To reposition and injury – (you must have a blue injury indicator box) simple move your mouse to the new location and click the area.

The injury indicator box will then turn Red. To delete an injury click on the red box to make it blue, then click on the delete button at the top of the page. The injury is then removed.

Close the anatomical picture and your injury information will be entered into the assessment box.

SKIN – select

No abnormalities

Not assessed

Hot

Cool

Diaphoresis

Lividity

Pale

Cyanotic

Jaundiced

Other

Mottled

Comments

HEENT – (Head, Ears, Eyes, Nose Throat)

No abnormalities

Not assessed

Head/Face

Facial droop

Dysconjugate gaze – eyes not tracking together

CSF – cerebral spinal fluid

Drainage

Battles Sign

Mass / Lesion

Other

Eye Left - dilated constricted non reactive blind other pupil size

Eye Right -

2 mm 3 mm 4 mm 5 mm 6 mm 7 mm

Neck - JVD Tracheal Deviation Stridor Subcutaneous air Other

Comments

CHEST

No abnormalities

Not assessed

Chest - Accessory Muscle Usage

Retractions

Other

Lung Sounds

Decreased LU LL RU RL

Wheezing LU LL RU RL

Rales LU LL RU RL

Rhonchi LU LL RU RL

Other LU LL RU RL

Heart Sounds

Decreased sounds

Murmur

Other

Comments

BACK

No abnormalities

Not assessed

Back

Deformity

Atraumatic pain

Scoliosis

Other

Comments

ABDOMEN

No abnormalities

Not assessed

Tenderness LU LL RU RL

Distention LU LL RU RL

Guarding LU LL RU RL

Mass LU LL RU RL

Other

Comments

PELVIS/GU/GI

No abnormalities

Not assessed

Pelvis

Tenderness

Unstable

Other

GU/GI

Incontinence

Hematuria

Rectal Bleed

Other

Comments

EXTREMITIES

No abnormalities

Not assessed

Delayed Capillary Refill LA RA LL RL

Abnormal Sensation LA RA LL RL

Edema LA RA LL RL

Atraumatic Pain LA RA LL RL

Weakness LA RA LL RL

Paralysis LA RA LL RL

Other LA RA LL RL

Comments

NEUROLOGICAL

No abnormalities

Not assessed

Neurological

Weakness – Left sided

Weakness – Right sided

Abnormal Gait

Facial Droop

Tremors

Slurred Speech

Other

SAVE your entries

NARRATIVE PAGE

CLINICAL IMPRESSION - PRIMARY IMPRESSION

a. Abdominal pain/problems

a. Airway obstruction

b. Allergic reaction

c. Altered Level of Consciousness

d. Behavioral/psychiatric disorder

e. Cardiac arrest

f. Cardiac rhythm disturbance

g. Chest pain/ discomfort

h. Diabetic symptoms

i. Electrocution

j. Epistaxis

k. Generalized weakness

l. Hemorrhage

m. Hypertension

n. Hyperthermia

o. Hypothermia

p. Hypovolemic/ shock

q. Inhalation injury (toxic gas)

r. No complaints or Injury/Illness noted

s. Obvious death

t. Other

u. Pain (nontraumatic)

v. Poisoning/drug ingestion

w. Pregnancy/ob delivery

x. Respiratory arrest

y. Respiratory distress

z. Seizure

aa. Sexual assault / rape

ab. Smoke inhalation

ac. Stings / venomous bite

ad. Stroke/CVA

ae. Syncope/fainting

af. Traumatic Circulatory Arrest

ag. Traumatic Injury

ah. Vaginal hemorrhage

SECONDARY IMPRESSION - Additional complaints that the patient may have

This is the same drop down list as the primary impression

INJURY DETAILS

PRIMARY

a. Bicycle accident

b. Bite

c. Chemical poisoning

d. Child abuse

e. Drowning

f. Drug poisoning (accidental)

g. Electrocution (lightening)

h. Electrocution (non lightening)

i. Excessive cold

j. Excessive heat

k. Fall

l. Fire & Flame

m. Firearm (accidental)

n. Firearm (assault)

o. Firearm (self inflicted)

p. Machinery accident

q. Mechanical suffocation

r. Motor Vehicle Accident

s. Non motorized vehicle accident

t. Radiation exposure

u. Railway incident

v. Rape

w. Self inflicted

x. Smoke inhalation

y. Stabbing/cutting (accidental)

z. Stabbing/cutting (assault)

aa. Struck by blunt / thrown object

ab. Venomous sting

PLACE OF INJURY

a. Home

b. Street / Highway

c. Doctors office

d. Nursing Home

e. Assisted Living Center

f. Hospital ER

g. Hospital – other or unspecified location

h. Dialysis

i. EMS provider

j. Other specified place

k. Rehabilitation Center

Once you select the Primary Injury the Details field and Place of Injury become mandatory fields

Along with a date field.

NARRATIVE BOX

Fill in your narrative about the incident in this area

SAVE your data

APPENDED NARRATIVE BOX

This area is the addendum section of the report

If you need to make changes to the Incident Detail, Patient Information or Billing page of the report the changes will be made on these pages and then you must document “why” the changes were made in the appended narrative box.

If you need to make changes to the Flowchart, Assessment or Narrative pages you will have to go to the Appended Narrative boxes and document the changes along with why you are making the changes.

This area date and time stamps the changes made to the document.

Spell check is available on the bottom of the page.

SAVE your entry

BILLING PAGE - Data entry into this page of the report may occur by people other than the responders. This will be department specific

PATIENT INSURANCE DATA

HIPAA Notice yes no

Billing Consent signature obtained signature not obtained unable to sign

Transport Refusal signature obtained signature not obtained unable to sign

(if applicable)

PAYER INFORMATION - Insurance information getsentered into this location

SAVE your data

PATIENT NEXT OF KIN DATA:

First Name

Last Name

Address

Relationship to Patient – Spouse, Parent, Sibling, Child, other

Check box to copy patient address to this area

SAVE your data

MEDICAL NECESSITY

REASON FOR HOSPITAL TO HOSPITAL TRANSFER

These areas are for the use of the billing people

CONSUMABLES – this area will be department specific and optional in use.

This will be a pre populated drop down list specific to the individual departments

Typically this area is used as a running inventory for items not supplied by the hospitals.

SPECIALTY PATIENT PAGE – These pages go into to specific patient information regarding the following categories.

Spinal Screening Page - This page documents the Spinal Assessment screening criteria for determining if Spinal Restriction is necessary

MVC – It is highly recommended that this page be filled out for any MVC. This page will give the receiving facility valuable information regarding the accident. Trauma Services at each hospital also track this type of information for statewide database. This page could become mandatory in the future.

CPR – It is highly recommended that this page be filled out any time CPR is performed. This page may become mandatory. The data on this page gives additional patient and intervention documentation for the arrest patient

OB – It is recommended that this page should be filled out for any OB patient. The information on this page will give the receiving facility pertinent information in regards to this pregnancy.

STROKE – It is highly recommended that this page be filled out for any suspected stroke patient. Currently this page uses the Los Angles Prehospital Stroke Screen but we will be changing it to the Cincinnati Stroke Screen. This may become a mandatory page in the near future.

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