Atch_1_Appx_5.9__MDGI_44-12_Amb_Operations....pdf

BY ORDER OFTJ JE COM:vt/\NDER

49TI I MEDIC/\L GROUP (/\CC)

MEDICAL GROUP INSTRUCTION 44-12

15 March 2016

Medical

AMBULANCE OJ>ERATIO S, PATIENTTRANSFERS, AND PATIENTNOTIFICATIONS

COMPLIANCE WITH THIS INSTRUCTION IS MANDATORY

NOTICE: This instruction applies to all personnel ass igned to or attached to the 49th Medical Group (49 MDG). This publica tion is ava ilable digitally in the Library Catalog. Refer recommended changes and questions abou t this publication to the Office of Primary Responsibility (OPR). Ensure that all records created as a result of processes prescribed in this publication arc maintaim:d l/\ W /\ ir Force Manual (AFMAN) 33-363, Management of Records, and disposed or in accordance with (IA W) Air r orcc Records Information Management System (/\FRIM S) Records Disposition Schedule (RDS). The use of the name or mark of any specific manufacturer, commercial product. commodity, or service in this publ ication does not imply endorsement by the /\ir Force (J\F).

OPR: SGO (Project Officer - SGOMA) Supersedes: MDGI 44-12. OJ Oct 2013

Approved by: Col Paul Willingham Pages: 13 /Distribution: X

Purpose: This instruction establishes policy and procedures for the pre-hospital care and ambulance transport or patients lo referral medical treatment facilit ies. It implements American College or Emergency Physician ("Guidelines fo r Transfer of Patients'), the Consolidated Omnibus Budget Reconci liation Act of 1985 (COBRA), as well as AFI 44-102, Medical Care Management. Finall y, this instruction provides guidance for notification on incidents, accidents. deaths, suspected criminal acts, admissions, transfers, and unusual events.

This instruction requires culkcting and maintaining information protected by the Privacy Act of I W4. The authorities to co llect and maintain the data prescribed in this instruction are I 0 U.S.C. 55 Medic.:al and Dental Care, I 0 U.S.C. 8013, Secretary of the Ai r Force; powers and duties; delegat ion by. and LO. 9397. System notice r044 AF SG E applies. Privacy /\ct statements required by /\ir Force Instruction (/\Fl) 33-332 arc either incorporated in the body of the form or in Dt.:partment of Defense (DD) Form 2005, Privacy Act Statement - I lcallh Care Records.

Summary of Revis ion . This document has been substantially revised and must be completely reviewed. This operating instruct ion provides better guidance on ambulance operations as well as in-night emergency ( llT) response and declaration of death authority. This instruction incorporates specific guidance on Mental Health transfers. In addi tion, it includes updated transfer processes for all clinics to include revised MDG Forms.

2 MDGI 44-12 15 March 2016

I. Ambulance Service Operations. . ' .

1.1 Emergency Services. Ambulance service for I lolloman Air Force Base (HAFB) and a limited surrounding area is provided 24 hours a day by the Ambulance Response Element (ARE). In the event that the /\RE is unavai lable, secondary ambulance coverage will be provided by American Medical Response (/\MR). ln the event that ARE and AMR are unavailable, tert iary ambulance coverage is provided by the Flight Medicine Clinic (FMC) at the discretion of Medical Operation Squadron (MDOS) and Aerospace Medicine Squadron (AMDS) Commanders (CC).

J.1.2. ARE wi ll respond after the transferring team or initiating personnel dials 911 from any land li nc telephone on the installation or contacts dispatch at DSN 572-7 171 from a non-landline telephone.

1.2. In Flight Emergencies.

1.2.1. ffE coverage will be provided by 49 MDG /\RE or FM C, if ARE is unavailable, 24 hours a day.

1.2.2. The on-call Flight Surgeon (FS) will be available for consultation for all IFEs. The on-call FS will determine i r the mishap aircrew needs to be evaluated at the fMC or transferred directly to Gerald Champion Regional Medical Center (GCRMC). If the individual aircrew member is emergent, then the patient will be transported to GCRMC expeditiously. If a FS is not readily available, /\RI: will transport the patient to GCRMC Emergency Room (ER) for evaluation.

1.2.2 . .1. The FS will respond to IFEs when requested by the Fire Chief, Wing Safety, or Supervisor or fl ying.

1.2.2.2. The FS must also respond to all IFEs where there is ri sk for physiologic incident to include G-LOC, hypoxia , ai rcrew disorientation, al tered mental status, loss of cabin pressure, rapid decompression. smoke and fumes, hydrazine exposure, or other physical symptoms or injuries reported by the aircrew.

1.2.3. /\ll IFl ~s require an ambulance response. These include but are not limited to:

1.2.3. 1. Flight Control malrunctions.

1.2.3.2. Engine abnormalities threatening night.

1.2.3.3. Planned arrested landings.

1.2.3.4. Fire or suspected lire aboard any aircraft.

1.2.3.5. Landing gear abnormalities.

MOGI 44-1 2 15 Mardi 2016 3

1.2.3.6. Environmental Control System (ECS) fa ilures.

1.2.3.7. J\ny known or s uspected physio logical inc ident, to include:

1.2.3.7. 1. Symptoms or decompn.:ssion events/ illness.

1.2.3 .7.2. Gravitational Loss orConsciousness (G-LOC).

1.2.3.7.3. Spatial disoricntHtion (Spatial D).

1.2.3. 7.4. I lypoxia.

1.2.3.7.5. Smoke or rumes in the cockpit.

1.2.3. 7.6. Emcrgcnci <.:s involving lost communications where another emergency may be present.

1.2.3.7.7. Known or suspected aircraft s tructural damage.

1.2.3.7.8. Ground emergencies involving fire on an aircraft. For other ground emergencies, ARE or fMC will be notili ed by 13ase Operations or ECC if medical assistance is required.

1.2.3.7.9. Confirmed 11~ dnt/.ine exposure.

1.2.3.7. JO. During non-duty hours. weekends, hol idays, or down days ARE will fo llow the notification matrix (J\ uachmcnt 2) and notify the on-ca ll FS if any aircrew require medical attention. /\RI·: ''ill notit) the on-call FS if the aircrew member shows symptoms of hypoxia, symptoms o r decompress ion events/ illness, or if the emergency involves cabin pressure issues, smoke or fumes in the cockpit. spatial disorientation, G-LOC, or any physiologic incident. If unable to reach the on-call FS ARE will transfer the individual to GCRMC ER for further evaluation. Under no circumstances will a patient be brought into the clinic without a FS being physically present.

1.2.4. Equipment taken lO all IFl ~s :

1.2.4.1. Aviator's mask and MJ\-1 bottle

1.2.4.2. J\ hand held radio and cell phone.

1.2.5. Upon arrival at the pre-des ignated flight li ne s tandby position, the crew wi ll re po1t to the on-scene Fire C hier. The crew will remain on station until released by the Fire Chief, or until the emergency is terminated.

4 M DG I 44-12 I 5 Marcil :.W 16

2. Patient Transfers to Other Facilities.

2. 1. Transfer Operations.

2.1.1. Patients requiring care beyond the capability of the 49th Medical Group will be transferred to an appropri ate medical treatment fac ility after coordination w ith an accepting provider and nurse at the recei ving fac ility. /\II patients requiring Advanced Life Support (ALS) or Basic Life Support (BLS) will be transferred by ARE if avai lable. If ARE is unavailable, transport must be coordinated ' ith /\MR.

2.1. 1.1. The transferring provider will determine the level of care requi red fo r the transfer of all patients. This information is proviclccl to the ARE, AMR, or FMC both verba ll y and in writing prior to the transfe r using th<.: 49 M DG Form 0-26a and 49 MDG Form 0-26b, 49 Medical Group Patient Transfer Onl<.:r.

2. 1.1.2. Any patient on a cardiac monitor at any c li nic in thi s fac ility, and who is being transferred to a cardi ac monitored bed at any other medical facility, will be on a cardiac monitor/defibrillator for the duration of transport by ambulance. This information will be provided to the transkrring service. If /\M R is transforring service, then the Department of Public Safety (DPS) 'viii be notilied pri or to the transfer. DPS can be reached by calling (575) 439-4300.

2.1.2. In the event that a pati ent requi res transport beyond a 60 minute rad ius from the 49 MDG, the MDG/SG I I (ChicJ'or Medical Staff) or the MDG/CC will determine the transport team.

2.2. Patient Transfers to CCRMC ER.

2.2.1. GCRMC ER will provide medical direction to the fi eld unit v ia radio or telephone for a ll patients being transported to GC R.M C. ARE personnel will contact the Emergency Contro l Center (ECC) for noti lication or th<.: /\ Itc's departure and return to the installation. A ll 911 responses and transport s performed by the /\RE, /\MR, or FMC will be documented on 24-hour /\RE Events Log.

2.2.2. ARE will maintain t\\O-\\ay radio or telephone communication with GCRMC ER for medical direction while pro' icling pre-hospital care. The 49 MDG will defer medical control authority to OC R. MC l:R for all pre-hospital ambulance responses wi th exception to IFEs.

2.3. Mental Health Patient Transfers.

2.3.1. M ental Health pa ti en ts rc;quiring transfer lo a more definitive facili ty wi ll be transferred e ither v ia des tinati o n specific transport teams, ARE, or AMR in the event that /\RE is unava ilable, based on the status of the patient and location of accepting facility. For local, voluntary, cooperative patients, the patient's command or fami ly mem bers can prov ide transportation to the local accepting fac ility. For patients that are unable to be transported via their command or fami ly members for medical or psychiatric reasons and/or

MDGI -l4- I 2 15 Marcil :20 I (> it is deemed they need more rapid em ergent treatment the M ental Health Flight wi ll contact ARE via dispatch to arrange a patient transfer after obtaining an accepting provider and filling out all required form s. /\RI ~ wi ll respond after the transferring team dials 911 from any landline telephone on the installation or contacts dispatch at DSN 572-7171 from a non-landline telephone. G iven the limited be d availability in our local area patients are often admitted to other regional facilities where transportation is provided by the accepting facility. The 49 MDG has entered into a Memorandum of Agreement with these facilities for transportation and care of 49 MDG patients.

2.3.2. If at any time the patient becomes difficult to handle, exhibits threatening behavior, or presents a risk of harm lo self or others, Security Forces will be contacted immediately by dialing 911 from any landlinc telephone. Security Forces will deem and take appropriate matters to ensure the safety of the patient and staff members.

2.3.3. If the patient is being transported on a non-voluntary basis the transferring provider must complete the 49 MDCJ 1:orm 0 -11 3, Involuntary Hold Form in addition to the transfer paperwork outlined in paragraph 2.4. The In voluntary Hold Form must be signed by a licensed physician or psychologist. This form is pan o r the transfer packet.

2.4. Initiating the Patient Transfer/Documentation and Paperwork.

2.4.1. The transfCrring phys ician wi ll determine the level of care requi red for the transport of all adu lt/pediatric pal icnts. This information is provided to AMR or ARE prior to the transfer.

2.4.2. The provider initiating the transfer, whether through ARE or AMR, will complete the "Transferring Provider's Orders" section of the MDG Form 0-26a. The physician will sign their portion of the form. The provider initiating the transfer is responsible for obtaining an accepting physician at the receiving facility.

2.4.2.1. If the transfer is being performed by ARE, the initiating provider will complete the ARE Physician Certification Statement wh ich can be found in the transfer book at each clinic. If the transfer is being performed by /\MR, the initiating provider will complete the AMR Physician Certification Statement which can be found in the transfer book at each clinic.

2.4.3. Providers, nurses, or medical technicians involved in the patient's care will give the accepting nurse report before the patient leaves our MTF. This wi ll be documented in the "Provider/Nurse/Tech Report Called to Accepting Facility" section of the MDG Form 0-26a.

Any specia l pre-transrer medical or administrative requirements will be determined at that time.

2.4.4. Nurses or medical technicians involved in the patient's care will give the transport serv ice staff report before the patient leaves the MTF. This will be documented in the "Provider/Nurse/Tech Report to Transport Service Staff' section of the MDG Form 0-26b.

2.4.4. t. Nurses or medical technicians involved in the patients care will ensure that all necessary items are provided to the transport service staff by fo llowing the check I ist on MDG Form 0-26b.

6 M DG I 44- 12 I 5 March 2016

2.4.4.2. Prov id~rs. nurs,cs. or medical technicians involved in the patient's care wi_ll ensure the

- patient or legal guardian signs MDG form 0-26b consenting to be transported.

2.4.5. Transport team staff" ill sign the bottom the MDG Form 0-26b signifying that the form has been completed. an accepting fac ility and physician have been identified, all necessary information has been provided. any and all orders have been clarified, and that the patient is ready for transport.

2.4.5. l. The patient has the option to refuse ambulance transport. This will be documented on the third and last page or the AF Form 552. The patient will sign the "I Refuse Treatment/Transport" block at the bottom or page three or the AF Form 552. The patient will also read and sign the Liability Wai ver paragraph at the top of the last page of the J\f Form 552. In the event that the patient is refusing transport requested by a MTF provider, the provider must annotate on the AF form 552 and the MDG Form 0-26 alb that they have discussed the possible ri sks ofrefusing transport with the patient.

2.4.6. The original or copy of the transfer information sheet will be sent with the ARE in order to properl y annotate/update the clinic daily events log. ARE will ensure all paperwork is provided to the MTF's outpatient records department for filing into the patient's medical record once all sheets have been propcrl) lilied out. Paperwork will be provided to the outpatient records department by J\ RE "ithin 72 business hours of the transport.

3. Other Ambu lance Operations.

3.1. Ambulance covc.:rag<.: of Changes of Command, retirement ceremonies, static displays, and any other event will be coordinated on case by case basis through the /\RE NCOlC.

3.1 .2. A mass casualty incident (MCI) is defined as any incident in which emergency medical services resources, such as personm:I and equipment, arc overwhelmed by the number and severity of' casualties. In the case or a MCI, the senior crew member will assume the role of the medical on-sc<.:n<.: commander (MOSC). Upon verbal report from the Fire Chief, the MOSC wi ll determine the need l(>r addit ional resources and begin coordinating medical activities including the request or addi tional personnel and vehicles as well as the stand-up of the Medical Control Center (MCC).Th<.: second staff member will begin preparing triage and transportation areas fo r the initial triag<.: and the treatment of incoming casualties.

3.1.2.1. Deceased persons will not be transported by military ambulance. Upon arrival at a scene where an apparent death has occurred, the Incident Commander will notify medical direction or the Medical Officer of the Day (MOD) for declaration of death. The MOD can be reached by contacting (575) 572-2778. In the event that medical direction or the MOD is unavailable or will be delayed. authori ty to declare death is delegated to the Office of the Medical Investigator (OIVll). Stat<.: or cw Mexico. OM I can be reached by contacting (505) 272- 3053. OM ! will be rnntact<.:d regard less of the party declaring death . The crew member will document the time VIOi) or OM I arri ved on scene on the AI' Form 552.

MDGI ..J -1-12 15 \l an.:h 201<> 7

4. Aeromedical Evacuations.

4.1. In the event J-1/\FH is the termination point for an aeromedical evacuatidn patient, TRI CARE Operations and Patient Administration ( TOPA) Flight will contact FMC. If FMC is unavailable, ARE will be contacted to accompany the TOPA representative to meet the patient.

5. Hazardous Materials.

5.1. In the event that an individual is being transported by ambulance to GCRMC following exposure to a lul/.ardous material , the responding field unit will instruct a member from the patient's duty section to fax the appropriate Material Safety Data Sheet (MSDS) to GCRMC ER (575-443-790 I). The responding Jie ld unit wi ll provide the patient's duty section with the fox number. The responding field unit will fo llow up with GCRMC ER to ensure the MSDS sheet was received.

6. Patient Notification Processes.

6.1. All patient notificat ion processes arc referenced in MDGJ 4 1-5, TRICARE Operations and Patient /\dmin (TOP/\) Services.

6.2. Unscheduled Admiss ion/Transfer Notification for Active Duty.

6.2.1. During Duty Hours.

6.2.1.1. The individual clinic initiating the patient transfer is responsible for notifying the TOPA Flight regarding the transfer and admission to another facility. The TOPA Flight is responsible for making squadron notifications regarding all J JAFB active duty admissions to GCRMC, or any other treatment facility during duty hours. TOPA Flight noti fies the 49 MDG Commander and SU I I immediately if there is an active duty admission.

6.2.2. After Uuty Hours.

6.2.2.1. fn the event that an active duty member is admitted to an outside facility after hours, the admitting facility notilics /\RI : at (575) 491-6789 or (575) 491-6788. ARE notifies the TOPA Flight on-call represen1a1i ve. "ho in turn, notifies 49 MDG Commander and SGH.

6.3. Unscheduled Admiss ion/Transfer Notification Active Duty Dependent or Retired Senior Officer.

6.3.1. During Duty J lours.

6.3.1.1. The clinic initiating the patient transfer is responsible for notifying the TOPA Flight. The TOPA fli ght is responsible !or notil'ying the sponsor's squadron when a HAFB active duty dependent is admitted or trans l erred to another medical treatment facility.

6.3.1.2. ARE is notified at (575) 491 -6789/6788of hospital admissions for all retired senior

8 MDGI -l-l - 12 15 March 2016 officers in the grade or Colonel and above. TOPI\ Flight notifies Headquarters Air Combat Command Surgeon ()encral ( I IQ /\CC/SO) of' hospital admission of all senior officers (AD & Retired) in the grade or Colonel and above. · · ·

6.4. ARE wil l provide the MDOS/CC. SOH, SOI-IQ, and ARE NCO TC with a summary of all transfers performed at thl! l.!nd or each 24 hour shift. This summary is documented on the AFSPC Form 1924, Events I .og. and is sent to the MOOS/CC, SOH, SGHQ, and ARE COIC via an encrypted email.

7. Info rmation Tha t May be Provided During Notification.

7. 1. Patient confidentiality must be adhered to when authorized notifications are made. The following information may be released without the patient's consent if active duty: name and grade (if applicable). date or admission/disposition, sex, component, base, organization, marital status, and occupation. Exception: The Command Post (and the individual's commander) may request and receive additional informat ion II\ W official Air Force directives (AFT 41-210, Pmienf Administrntion F1111ctio11s. and MDGI 41-5, 1'RJCARE Services).

7.2. Description or disease or injury. general factual circumstances, and general extent of the injury cannot be released without the patient's informed consent. Do not specify physical location or description that muy be embarrassing to the individual or reflect bad taste. Persons making non-directed line (e.g .. Command Post line) telephonic inquiries will not be given medical information unless the caller is known personally to the receiver to be the individual's commander.

8. Noti fication of Un us u al Events.

8.1. The individual clinic will notify the ARE, who in turn notifies the Security Forces Squadron and/or the Command Post if an active duty member and/or HAFB active duty dependent presents to the 49 MDG for an unusual incident. The Security Forces Squadron will be notified if any patient presents to the 49 MOO for any unusual event (light victim, accident, assault, drugh1l<.:ohol-relatcd incident, an imal bite, death, etc.). If in doubt, the 49 MDG Commander should bl! contacted. Sec attached checklists for specific notifications (Attachment 2).

9. Responsibilit ies:

9. 1. Personnel.

9.1.1. It is the responsibility or all personnel, military and civilian ass igned to or employed by the 49 MDG, i.e., physicians. nurses. mental health personnel, and medical technicians, to adhere to the guidelines or this instruction.

9. 1.2. MTF CC.

9.1.2.1 . Will perform duties as uu1linccl in AFI 44-102, Medical Management.

MDGI -1-1-12 15 \larch 201 <i

9.1.2.2. In coordination 'vvith the MOOS/CC, wi ll ensure a privi leged provider is appointed EMS Medical Director or Competent Medical Physician (CMP) to oversee the ARE and supervise technician training and performance.

9.1.3. EMS Mcdirnl Director or Competent Medical Phys ician (CMP).

9.1.3.1. Survey professional performance of all technicians working in the ARE.

9.1.3.2. Sun ey professional perrormance or all flight medicine technicians when they are performing IFh or 91 I duties.

9.1.3.3. Review ambulance run forms to include AF form 552, Pre-hospi tal Evaluation/Care Report, MDG Form 0-26a, MDC1 Form 0-26b, and any other forms necessary to complete the patient transfer.

9.1.3.3.1. Review of all forms "ill be completed within 72 hours of end of out-going shift.

9.1.3.3.2. All forms will be reviewed for the following:

9.1.3.3.2.1. Proper documentation.

9.1.3.3.2.2. Ensure abnormalities are properly addressed (i.e., Blood Pressure (BP), Heart Rate (HR), RR. Pulse ox. injuries)

9. l.3.3.2.3. Ensure contac t \·Vi th Medical Control was established in a timely manner.

9.1.3.3.2.4. Any deviations from Paramedic/ Uni ted States Air force (USAF) EMT protocols are clearly documented as being ordered by medical control and wi thin their scope of care.

9.1.3.3.2.5. Medical Din.:c1or documents concurrence that standard of care was met.

9.1.3.3.2.6. Jdcntiry any trends or areas requiring additional training.

9.1.3.4. Ensures all training requirements arc met IA W AF! 44- 102. Medical Management . Also ensures local training includes participation in MDG Code Blue exercises and other joint training with MDG and Fire Department personnel.

9.2. EMTs Performing Ambulance Duties and T ransfers.

9.2.1. Maintain a valid U.S. driver's license.

9.2.2. Maintain a valid CJovernmcnt driver 's License with Ambulance 4X2 and 4X4.

9.2.3. Follow Paramedic/US/\F 1:MTapproved pre-hospital care protocols.

9.2.4. Maintain two-\\ a) radio or 1clephonc communication with GCRMC ER for medical

10 MDGI -1-1-12 15 March 2016 control while providing pre-hospi tal care (24-hours/day, 7 clays/week). The 49 MDG will defer medical control authority to GCRMC ER for all pre-hospital ambul~nce responses except IFE

' " ' responses.

9,2.5. Document al l telcphom: and radio orders, to include the name of the individual giving the order, exact order read back to the physician, and the time the order was carried out.

9.3. EMTs Performing I FE/Field T reatment Team Duties.

9.3.1. Maintain a valid U.S. driver's license.

9.3.2. Maintain a Government driver's license with Ambulance 4X2 and 4X4.

9.3.3. Follow USAF l ~ iVIT approved pre-hospital care protocols.

9.3.4. Have /\F !MT 483. Fli?,ht Une Driver's certificate of competency.

9.3.5. Maintain two-way radio or telephone communication with GCRMC ER for medical control while providing pre-hospital care (24-hours/day, 7 days/week). The 49 MDG wi ll defer medical control authority to GCRMC ER for all pre-hospita l ambulance responses except I Fl ~ s rl..!spunses.

9.3.6. Document all tclcphonl..! and radio orders, to include the name of the individual giving the order, exact order read back to the physician, and the time the order was carried out.

9.4. Contract employees wi ll perform responsibil ities IA W contract/company requirements.

10. Staff Educat ion.

10.1. All clinical staff assigm:d 10 the 49 MDG wi ll be trained on the patient transfer process during clinic orientation. /\ddi1iunally , use of SBA R technique wi ll be implemented in this training. Applicable sections include staff assigned to the Dental, £7amily Health, Internal Medicine, Pediatric. Women's l lcalth, Mental I lcalth, Flight Medicine, and /\RE clinics.

Training will include but is nut limited to the location and use of the transfer packet/ forms and the how to relcrcnc.:e the.: IO\\er right hand corner of the form to ensure carbon/duplicate copies arc forwarded to appropriate locations (transport service, patient record, etc). A more detailed training wi 11 occur when c I inica l staff is orienting to their speci fie work centers.

10.2. Training on the transfi.:r process wi ll occur during all code blue exercises. In addition, simulator training and othcr staff education opportunities will be utilized to emphasize the patient transfer process.

11. Forms Management.

11.1. The following sections provide direct patient care and arc required to have transfer packets on hand at all times: Denial. lmcrnal Medicine, family Health, Pediatrics, Women's Health, M DG I -1-l-1:?. 15 \ lan.:11 ~o I <1

Mental Health, Flight Medicine. and ARE.

ll.2; Transfer packets will also be maintained on all code carts in the faci lity. This wi ll be verified during all code cart checks.

11.3. The /\RE NCOIC is responsible for maintaining and ordering all forms mentioned within this instruction. It is the clinic 's responsibility to notify the ARE NCOIC when more fonns are needed fo r their area . ii ~

Attachments 1 . References

2. ARE otification Roster (Matrix)

PAUL A. WILLINGHAM, Col, USAF, MSC Commander, 49th Medical Group

12 MOG I 44-12 15 March ~016

Attachment I

References

I. A.Fl 33-332. Primn• Au JJrngram

2. AFI 41 -210, Patient 1ld111inisrra1ion Functions

3. AF! 44-102, Atfedical ( 'ure Management

4. A.F l 48-149, Flight mu/ Opernrional Medicine Progrnm (FOMP)

5. MDGJ 41-5. 'fricore Operutions and Patient Admin Services

6. MDGI 41 - 18. Amb11/ance /)river "fraining/lnventOJyllnspection

7. Memorandum or Understanding. A.MR and 49 MDG

8. Memorandum or Understand ing, 49FES and 49MDG

9. Memorandum ol' Understanding, OM! and 49 MOO

I 0. AF Form 552. JJre-/10.\'fJitul /:'11a/uation/ Care Report

11. MDG Form 0-26a/0 -2(>b. JJatient Tram:fer Order

12. A MR Physician ( 'e l'I (/inti ion Statement

13. ARE Physic ian Cert (/icotiun ,)'ratement

MDGI 4-1-12 15 ~larch ~o I<>

Attachment 2

AMBL'L\:\CE RF.S PONSE ELEMENTNOTIFICATION ROSTER

u Ii:!

Q

Air El':ic IA Ambulam·c I ~

D:tnl:ll?.C Animal Bi les• Assaul ts: 111.\1 l'yskal/Scrnal < 18 v/o Bomb Th real I Death I

DCS I

Orul!/Alcohol Iii\ !

fi re in Clinic I

IF£

Sn1c111 Ou1ai:c II i\l:t)) t"nsuahy I 1\ k S>lll!C Pi ll l'IU'l'I l'I Transfer II Ouarlcrs Pl lladialion I F.x11os urc F:idlil\· Sccuri11· II Admission C\'i\ I Spouse/Child II Family Abuse VSl/S l/111 Active II Outv MC l\ lislrn" Vll's/ACC Visi1 I A1l111 issions (06~)

S11/CC (06+) AD I

on Ua)c S nk i1k AHcmpl , I ltlt·ation, Gesture

1-Notil)' 1n11ncdiatcl) ,\-/\c1i\·c dut) SC P-Designated Rep SGll-Dcsignatcd Rep COH-MDOS Sup

,__l_ ~ 1.\1

1\1

2 I 2 1.\1 I I i 1.\1 .2

I I '-'I I~ -

I

2.\1

I

1.\1

I - I

I

2 I ~ \I

I i J i i I

2 I I

" e -= "- ct ii ] ;;: f :i:

~-· ] E 0 "B E .. 0 ~ c rL_ :;

I

I

IAO I

I I I I I ---

I

IAU I

1 I I I I I

I I 2 ----

I I 2 - 1.\1)\'

I.\ I,\ I

I I I

I ,\I) I

IAD\I

I

IAO \ ' 2

1.\1)\ " 2

---- -l,\I)\' I l ~ i\ l -No11 I) 11' /\ !!Xi p•·1,u1111l'I ••-OSI lll\ ohcd

\'-Retired u6 or abovc/CMSgt II-Noti fy prior to 0730 MTG \\ G/SE-Wg Safety sc;. \ -D"1gnat,·tl lfrp c;:-.-Ocs1gnatcd lh·p 2-Notif) I'!! 0800 next day

:i: c.

.~ " u :;; "' < :i: "' z Ii:!

f; ~ ~ ~ ~ ~ ?. .~

I li\I I

I I I I I

I I I I i\I 2 I 1 ~-- 11\1

2i\I I I I I I I I

2 2 I I I

I I 21\1

I I Ci\1 l i\I I 1\1 21\1 I

21\1 11\1 2 2

I I 2 2

I 2 2 l i\I 11\1 21\1 I I

C-06 or abovc/CMSgt " -Ir crit ical 1>-11/\FB /\ct iv~ Duty dcp &-If uncxp~ct~d •-oo:b;JSc Animal Control II (-139-4300) I - 1 f pt tx i.6uncxpcc1cd e u w ~ ~ ~ ex

"' > 8 c:: ,:, ~

I

I I

I

I I

I

1\1

I

49TH MEDICAL GROUP PATIENT TRANSFER ORDER

NAME: (Last, First, Ml) I FMP/SPONSOR SSN: I AGE: I DOB: I BRANCH/RANK/STATUS/UNIT: SPONSOR'S NAME:

TODAY'S DATE: I ACCEPTING FACILITY: I DEP/UNIT/RM : ACCEPTING PHYSICIAN:

TIME DISPATCH (911) I SPOKE TO: (Rank, Last Name, First Name) REASON FOR TRANSFER:

CONTACTED:

TRANSFERRING PROVIDER ORDERS

PATIENT CATEGORY: DIAGNOSIS: ALLERGIES: CURRENT MEDICATIONS:

J CATEGORY 1: STABLE

0 CATEGORY 2: STABLE/UNLIKELY STATUS CHANGE

0 CATEGORY 3: STABLE/RISK FOR STATUS CHANGE

0 CATEGORY 4: UNSTABLE

VITAL SIGNS FREQUENCY:

EVERY FIVE MINUTES WHILE TRANSFERRING c PER FACILITY PROTOCOLS EVERY FIFTEEN MINUTES WHILE TRANSFERRING c Other:

MEDICATION THERAPY: DOSE: ROUTE: FREQUNCEY: CONCENTRATION:

IV THERAPY: I TYPE: I AMOUNT: I RATE: I SIZE: I SITE: I D/C:

I I I I I I

OXYGEN THERAPY: I FLOW RATE (L/MIN): I ROUTE: PULSE OX PARAMETERS:

I I

OTHER PHYSICIAN ORDERS/PARAMETERS:

ORDERING PROVIDERS PRINTED NAME/STAMP: I ORDERING PROVIDERS SIGNATURE:

PROVIDER/NURSE/TECH REPORT CALLED TO ACCEPTING FACILITY

PROVIDER/NURSE/TECH NAME: I ACCEPTING FACILITY: I PHONE NUM BER CALLED: l SPOKE TO: I TIME CONTACTED:

SITUATION:

BACKGROUND:

ASSESSMENT:

RECOMMENDATION.

PROVIDER/NURSE /TECH PRINTED NAME: I PROVIDER/NURSE/TECH SIGNATURE:

MDG Form 0-26a 20160101

Records M ainta ined at: Patient's Name: (last, First, Ml)

DOB: Sponsors SSN:

Status: Relationship to sponsor:

Sponsor's organization: Sponsor's Name:

"This document contains information which must be protected IAW AFI 33-332 and DoD regulation 5400.22, Privacy Act of 1974 as amended applies, and it is for official use only"

MDGCOPY

PROVIDER/NURESE/TECH REPORT TO TRANSPORT SERVICE STAFF

PROVIDER/NURSE/TECH NAME: I TRANSPORT TEAM STAFF: I TIME OF TRANSPORT STAFF ARRIVAL:

SITUATION:

BACKGROUND:

ASSESSMENT:

RECOMMENDATION:

ITEMS PROVIDED TO TRANSPORT SERVICE STAFF:

IN TIA LS

-- COPY OF SF 600 (INCLUDING LABS, EKG, X-RAYS, ETC)

-- 49 MDG FORM 0-26, PATIENT TRANSFER ORDER

-- 49 MDG FORM 0-113, INVOLUNTARY HOLD FORM (REQUIRED FOR MENTAL HEALTH HOLDS)

-- IF INVOLUNATRY HOLD, SGH & SGHQ NOTIFIED VIA ENCRYPTED EMAIL

-- PHYSICIAN CERTIFICATION FOR AMBULANCE SERVICES (IF TRANSPORT BY AMR)

-- All PATIENT RECORD FORMS SENT WITH TRANSPORT TEAM TO COMPLETE NOTIFICATIONS AND

EVENTS TRACKING LOG AND THEN SENT TO THE APPROPRIATE OUTPATIENT RECORDS ROOM

FOR FILING INTO THE PATINET'S RECORD.

Privacy Act Statement: (this form is subject to the Privacy Act of 1974. Use Blanket PAS, DD Form 2005).

In the case of military personnel, the requested information is mandatory because of the need to document all active duty medical incidents in view of future rights and benefits. In the case of all other personnel/beneficiaries, the requested information is voluntary. If the requested information is not furn ished, comprehensive health care may not be possible, but CARE Will NOT BE DENIED. This all-inclusive Privacy Act Statement will apply to all requests for personal information made by health care treatment personnel or for medical/dental treatment purposes and will become a permanent part of your health care record.

Transfer Consent: (Subject to the Privacy Act of 1974. Use Blanket PAS. DD Form 2005) I acknowledge that my medical condition has been evaluated and explained to me by the physician or other qualified medical person, who has recommended that I be transferred. The potential risk and benefits of such a transfer and the probable risks of not being transferred have been expla ined to me and I fully understand them. The medical benefits expected from the care that will be received outweigh the potential risks of the transfer to the patient (unborn child in case of labor). The receiving hospital has an accepting physician, available space, and qualified personnel and has agreed to the transfer. The 49 MDG will provide qualified personnel and equipment for the transport. With th is knowledge and understanding, I agree and consent to be transferred.

PATIENT/GUARDIAN SIGNATURE: I RELATIONSHIP TO PATIENT: I WITNESS: I DATE/TIME:

TRANSPORT TEAM STAFF PRINTED NAME: I TRANSPORT TEAM STAFF SIGNATURE: I TRANSPORT TEAM TIME OF DEPARTURE:

MDG Form 0-26b 20160101

Records Maintained at: Patient's Name: (Last, First, Ml)

DOB: Sponsors SSN:

Status: Relationship to sponsor:

Sponsor's organization: Sponsor's Name:

"This document contains information which must be protected

IAW AFI 33-332 and DoD regu lation 5400.22, Privacy Act of 1974 as amended applies, and it is for official use only" MDGCOPY