Patient Evacuation Critical Information and Tracking Form



|[pic] |Hospital: 518.324.1000 | |Empire County Hospital |

| |HCC: 518.324.4HCC | | |

| |Tracking: 518.324.TRAK | | |

| | |Patient Evacuation Critical Information and Tracking Form |

|Receiving Facility |Movement Times |Place patient identity label or imprint here or write in patient information |

|____________________ |At Holding: ______ |Name: Last ____________________First _____________________ |

|____________________ |At Loading ______ |MR #: ___________________________________________ |

|____________________ |Left Facility ______ |Age: _______ Gender: M F DOB: ____/____/____ |

|____________________ |Arrived Dest.______ |Admission Date: ____/____/____ Unit: ____________ |

|____________________ | |Attending Physician: _____________ Room or Bed #____ |

|____________________ | | |

|Patient Mobility Level |Minimum Staff to Loading Area |Transport Agency: __________ Unit/Vehicle # _______ |

|Transportation Assistance Level | | |

| | |Transport Vehicle |Equipment / Items to Accompany |

| | | |Patient |

| Behavioral Health (blue) |Clinical |Non-Clini| | |

| | |cal | | |

|TAL 3 [pic] Ambulatory |0 |1:5 | Transit/School Bus | Oxygen |

|TAL 2 [pic] Wheelchair |0 |1 | Wheelchair Van / Ambulette | Suction |

| | | |Other (specify) __________ | |

|TAL 1 [pic] Non-Ambulatory | | | | Infusion Pump |

| |1 |1 | BLS Ambulance | Ventilator |

|TAL 1 Moderate Acuity |1 |1 | | Medications |

|TAL 1 Critical Care |1 |2 | ALS Ambulance | Critical Supplies |

| | | |Air Ambulance / MedEvac | |

| | | |Isolette / Neonatal Ambulance | |

|TAL 1 Interrupted Procedure |2 |2 | | Medical Record |

|(specify)________________ | | | | |

| | | | | This GO Pouch |

|TAL 1 Arm Carry |0 |1 | Patient Accompanied by Guardian | Other __________ |

|Isolation Status | Contact | Droplet | Airborne | Other __________ |

|Primary (Significant) Diagnosis: |Relevant Co-morbidities: Cardiac Diabetes |

|___________________________________________ |Hypertension Other ______________________ |

|Advance Directives |Name/Contact #_________ | Interpreter Needed? ASL Language: _______________ |

| DNR | DNI | Healthcare Proxy | Living Will | MOLST | Copy Enclosed |

|Allergies | None Latex Other: ________________________________________________________________________ |

|Mental Status | Oriented | Alert | Lethargic | Mildly Confused | Severely Confused |

|Behavior Problems/Safety Risk | None | Wanders | Elopement Risk | Verbally Abusive | Physically Abusive |

|Fall Risk | None | Low | High |

|Restraint | Vest/Posey Wrist/Mitt 4-Point Other ____________ |Date / Time Applied: ________ |

|Special Requirements | Oxygen (mask) lpm ____ | Oxygen (cannulae) lpm____ | Suction | Seizure Precautions |

|IV Access | Saline Lock | Continuous | PICC Line | Central Line |

| Other Intravascular Device ________ | Solution / Rate __________ | Tube Feeding |

|Transfers | Independent | Supervision | Partial Assist 1 | Partial Assist 2 | Total Assist |

|Activities of Daily Living |

| Independent | Supervision | | Partial Assist | Total Assist |

| Continent | Incontinent Bowel | Incontinent Bladder | Other _______ |

|Diet | Special: ______________________ |Consistency | Aspiration Precautions |

| NPO | Regular: |Regular |Ground | Pureed |Thickened |Liquid |

|Personal Assistive Devices with the Patient |

| None | Cane | Walker | Personal Wheelchair | Glasses |

| Dentures | Hearing Aid | Prosthesis Type: ____________ | Other ________ |

|Notifications (name/date/time) |Family: |Private MD: |

|Last Actions Prior to Departure Document time and findings |

|Last Temperature |Last Heart Rate |Last Blood Pressure |Last Accu-Check _______________|Last Breath Sounds |

|_______________ |_______________ |_______________ | |_______________ |

|Last Medications Given (name/dose/route/time): |Last Meal (food/date/time): _____________________________________________ |

|_____________________________________________ | |

|Next Medications / Intervention Needed None until: _____________________________ |

|Name |Day/Time Needed |Administered? |By |Date |Time |

| | | Yes No | | | |

| | | Yes No | | | |

| | | Yes No | | | |

|Notes During Transit Document all care given or status updates. Use other side if needed. |

|Time |Note |

| | |

| | |

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