BASE HOSPITAL FORM - Los Angeles County, California

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BASE HOSPITAL FORM

Log #_________________________

Sequence #____________________________________ Pg2

G

E N

Date

Provider Code

I N

Time

Unit______________

F O

Location___________________________________

Pt.#____of_____ Gender: M F N Peds Weight

Age___________

Yrs Mos Days Color Code: Wks Hrs Est. Too Tall

Weight________

Kg

Too Short

Hospital Code:

Phone Radio VMED28

9-1-1 Call 9-1-1 RE-Triage IFT

PROVIDER IMPRESSION

CHIEF COMPLAINT CODES

A mLAPSS S Met: Y N S Last Known Well: E

Protocol: ____________

S Date:

____________

S

M Time:

E LAMS Score:

N T

Medical

Hx:

Medications:

NKA Allergies:

LEVEL OF DISTRESS None MilD

O/P Q R S T

DNR/AHCD/POLST?

Moderate Y N

Severe MEDS:

P R I

ADE ________ ALB ________ AMI ________

O ASA ________

R BIC ________

CAL ________

FEN ________ GLU/GLP ________ KLC ________ MID ________ Morphine ________ NAR ________

T D10 ________ NTG ________

O EPI ________ OND________

TXS:

B BMV CPAP ETT King

A SMR GLucometer:

S DEFibrillatedX ___ CAR TCP

E AED-Analyzed AED-Defibrillated

Needle THoracost. Tourniquet(TK)

Unk

IV/IO Fluid ____cc OTher:

LOC ALERT Ox3 PUPILS PERL RESPIRATION CLEAR NORMAL rate/effort Capnography#:_____ SKIN NML Initial Rhythm:

P Disoriented

Unequal

TIDAL VOLUME: N + -

Waveform? Y N Pale Hot 12-Lead ECG Ordered? Y N

H Combative

PInpoint

Wheezes

Labored Apnea

ADV AIRWAY

CooL/Cold 12-Lead ECG @ ____:____

Y NoT Alert

Fixed/Dilated

Rales

Unequal Snoring

BS after ETT/King?

Diaphoretic E EMS Interpretation:

S NorMal for Pt I No Response

Cataracts Sluggish

RHonchi STridor

JVD Accessory Muscle Use

Y N ETCO2? + -

Cyanotic C NormaL ABnormal STEMI Flushed G Software Interpretation:

C

NormaL ABnormal STEMI

A IUP:_____wks

GCS

Glucometer

Cap Refill:

Artifact?

YN

L Suspected

Eye _______ Verbal _______ Motor _______

#1: _________ #2: _________ NoRmal

Wavy Baseline?

Y N

Drugs/ETOH

TOTAL GCS:

Repeat GCS (if applicable):

DElayed Glucometer Ordered? Y N

Paced Rhythm?

YN

V I T A L S &

O2@________lpm Titrated? Y N via: NC Mask BMV BloW by EXisting Trach. ETT King CPAP

IV: SL FC:_______cc Not Ordered IV Unable Refused IO PreeXisting IV

TransCutaneous Pacing @ mA: ________ Rate: ________ Capture? Y N Needle THoracostomy? Y N

Spinal Motion Restriction? Y N CMS Intact: Before After SMR Refused? Y N Tourniquet (TK)

TIME

B/P

PULSE RR O2 SAT PAIN CO2 #

ECG

DRUG/DEFIB SEDs past 48hrs?

Y

N DOSE

DOSE UNITS

ROUTE

RESULT

REFUSED

A R R E S

Witnessed by: Citizen EMS None

CPR by: Citizen EMS None

Arrest to CPR (in minutes) _______

Rtn of Pulse (ROSC)? Y N

Rtn of Pulse (ROSC) @ ___:___

T

PRN

T Resus D/C @ ___:___

X S

PRN

Resus D/C Rhythm

PRN

Total Min. EMS CPR: _______

No Apparent Injury B P

B P

BUrns/Elec. Shock

Trauma Arrest

Abdomen

T Critical Burn

R SBP 10ft Peds) Self-Inflict'd/Accid. Self-Inflict'd/Intent. Electrical Shock Thermal Burn HazMat Exposure Work-Related UNknown OTher:

MOIs:

CODE all options, CHECK actual destination:

CODE

ETA

CHECK ONE:

DESTINATION RATIONALE:

MAR

EDAP (age ................
................

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