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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