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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