J-0402000-06 Patient Care Report.pdf

U.S. Navy Fire & Emergency Services EMS Incident Report (Patient Care Report (PCR))

Page 1 of PCR Form – For Official Use Only When Filled

# Box Title Box Instruction 1 Incident # Fill in Incident Identification Number from Dispatch.

2 NFIRS # Fill in NFIRS Incident Identification Number.

Section I: Dispatch

3 Date (MM/DD/YYYY) The date dispatch was notified of the incident (MM/DD/YYYY).

4 Dispatch Notified The military/24 hour time dispatch was notified of the incident in (e.g., 2130).

5 Unit Notified The time the Unit was notified of the incident.

6 Unit Enroute The time the Unit was enroute to the incident.

7 Arrive Scene The time the Unit arrived on scene of the incident.

8 At Patient The time the Unit arrived made physical contact with the patient. Leave blank if there is no patient contact.

9 Arrive Destination The time the Unit arrived at the destination or transferred patient care.

10 In Service The time period the Unit was placed back into service and was available for another incident response.

11 Department The responder’s current fire department name (i.e. ####).

12 FDID The Departments assigned Fire Department Identification (ID) Number (FDID).

13 Station The Unit’s assigned current station (i.e. ####).

14 Responding Unit ID The responding units Identification destination.

15 Incident Location The location/address of the incident.

16 Mutual Aid Units/Agencies The department/agency name or Unit ID receiving or providing mutual aid.

17 Disposition (Transported, Refusal, DOA, Transfer)

Check the appropriate information.

Transported: To an MTF or Hospital Transfer: To another EMS Unit or Agency.

17a Destination/Transferred to The name and location of the destination or agency of transfer.

17b Due to (Protocol, Patient Choice, Closest, Diversion, Specialty Center: Trauma, STEMI, Stroke, Pediatric, Eye)

The justification of the destination or transfer location. Check the appropriate information.

Section II: Patient

18 Patient’s Name (Last, First, MI) The last name, first name, and middle initial of the patient.

19 DOB (MM/DD/YYYY) The Date of Birth (DOB) of the patient. If days or months, circle the appropriate information.

20 Age (D, M) The age of the patient in days, months or years.

21 Weight The weight of the patient in pounds (lbs).

22 Gender (M, F) The gender of the patient. Check the applicable information.

23 Street Address The street address of the patient’s official mailing address.

24 City The city of the patient’s official mailing address.

25 State The state of the patient’s official mailing address.

26 Zip Code The zip code of the patient’s official mailing address.

Section III: History/Medication

27 Chief Complaint Statement of chief complaint from the patient as result of the incident.

28 Medications (None) List of current medications used by the patient. If no medications are being used by the patient, check the None box.

29 HPI Statement of the History of Present Illness (HPI) of the patient.

30 Allergies (NKDA) Statement of current allergies of the patient. If unknown, check the Non Known Drug Allergies (NKDA) box.

31 PMH (None, UKN, Asthma, COPD, CHF, CVA, Diabetes, Heart Disease, Seizures, Renal Failure, Dialysis, Hypertension)

Check the appropriate box that applies the Patient’s Past Medical History (PMH).

31a PMH (Continued) Statement or list of continued PMH information.

Section IV: Physical Exam

32 Pertinent Physical Exam Findings A brief statement is required to inform the receiving provider for continued care and to justify information collected in section V.

Section V: Vital Signs / Interventions

33 Vital Signs Fill in the appropriate vital sign information of the patient(s) at the incident.

33a Time Fill in the appropriate information in military/24 hour time (e.g., 0900).

33b BP The patient’s Blood pressure (BP) data (i.e. XX/XX or XX/P).

33c HR The patient’s Heart Rate (HR) data.

33d Resp The patient’s Respiratory Rate (Resp) data.

33e Pa02 The patient’s blood oxygenation (Pa02) data.

33f GCS The patient’s total Glasgow Coma Scale (GCS) data.

34 Interventions

34a Intervention The name of the specific Intervention(s) conducted on patient.

34b Dose The dose given to patient, if applicable.

34c Route The route for the medical administration, if applicable.

34d Provider Sign initials for the person performing intervention.

Section VI: Narrative

35 Narrative A brief statement of the incident and care provided to patient.

This section continues on Page 2 of this form if needed.

Section VII: Signatures

36 Provider 1

36a Printed Name The First and Last name of provider 1.

36b Signature The provider 1’s signature.

37 Provider 2

37a Printed Name The First and Last name of provider 2.

37b Signature The provider 2’s signature.

38 Receiving Provider The receiving provider at the destination or transfer location for the Patient’s continued care fills out this section.

38a Printed Name The printed First and Last name of the receiving provider.

38b Signature The receiving provider’s signature. The receiving provider must sign in confirmation of receipt of this information.

39 Report Continued?

39a Yes/No Check the applicable information.

39b Page 1 of ___ Fill in additional page numbers if continued to other pages of the PCR paper form.

39c QA Review Initial if Quality Assurance review was conducted.

Page 2 of PCR Form: Sections V, VI & VII Continued. – For Official Use Only When Filled Section V: Vital Signs / Interventions

33 Vital Signs Same info as first page.

33a Time

33b BP

33c HR

33d Resp

33e Pa02

33f GCS

34 Interventions

34a Intervention

34b Dose

34c Route

34d Provider

Section VI: Narrative

35 Narrative A brief statement of the incident and care provided to patient.

Use this section to attach EKG strips. This section is the continuation on Page 2 of this form if needed.

Section VII: Signatures

36 Provider 1 Same info as first page.

36a Printed Name

36b Signature

37 Provider 2

37a Printed Name

37b Signature

38 Receiving Provider

38a Printed Name

38b Signature

39 Report Continued?

39a Yes/No

39b Page 1 of ___

39c QA Review

U.S. Navy Fire & Emergency Services Refusal of Care Form

Page 1 of Refusal Form – For Official Use Only when Filled

# Box Title Box Instruction Section I: To be completed by EMS Provider / Responder.

1 Patient Name The printed first and last name of the patient.

2 Date The current date (MM/DD/YYYY).

3 Incident # Fill in Incident Identification number from dispatch, if available.

4 Incident Location The location/address of the incident.

7 Criteria for Refusing Care Check all that apply.

8 This form is being provided to me because of I have: (check all that apply)

Check all that apply. If Medications or Other is selected, please provide the appropriate information.

Section II: To be completed by Patient refusing care or transport.

10 Patient Signature The patient’s or legal custodian’s signature.

11 Relationship (if not the patient) Check all that apply.

Section III: To be completed by EMS Provider / Responder.

13 Patient Disposition Check all that apply. If Law Enforcement or Other is selected, fill out the appropriate information.

14 Instructions If other, fill out the appropriate information.

15 Form Completed by F&ES provider printed first and last name.

16 I.D. # F&ES provider Identification number.

Section IV: To be completed by Witness.

17a Witness Signature The witness’s signature.

17b Name (Printed) The printed first and last name of the witness.

18 Address The street address of the witness’s official mailing address.

19 City The city of the witness’s official mailing address.

20 State The state of the witness’s official mailing address.

21 Zip The zip code of the witness’s official mailing address.

22 Phone The area code and phone number of the witness.

Commercial Printing Specifications/Instructions:

The form is comprised of two (2) pages to legally document a patient’s refusal of care or transport from Navy

F&ES.

Page Size Type Instruction

1 8.5 x 11 One-sided Print Regular Paper

This page is to be filled out by the Patient and retained by Fire & Emergency Services. It must be printed one-sided in black ink and filled out with blue or black ink.

2 8.5 x 9.5 approximately (to dashed line)

One-sided Print Carbonless Copy (White/Yellow)

This page is the carbonless copy that is retained by the Patient after the patient has filled out the necessary information and a witness has signed on Page 1. This page will not include Witness information section from Page 1.

Line Line

1 1

2 2

3 3

Due to: □ Protocol □ Patient Choice □ Closest □ Diversion □ Specialty Center: (□ Trauma □ STEMI □ Stroke □ Pediatric □ Eye)

Arrive

Destination In Service

Street Address

PMH: □ None □ UKN □ Asthma □ COPD □ CHF □ CVA □ Diabetes □ Heart Disease □ Seizures □ Renal Failure □ Dialysis □ Hypertension

Time

Dispatch Notified Unit

Notified Unit Enroute Arrive Scene At Patient

□ Yes □ No

ZIP CodeCity StateP at ie n t

Medications

□ None

Patient Medical History

Chief Complaint:

H is to ry

M ed ic at io n s

HPI:

Allergies: □ NKDA

Narrative

Route Provider

Printed Name:

Signature:

Report Continued?

Disposition: □ Transported □ Refusal □ DOA □ Transfer

Printed Name:

Signature:

Interventions

S ig n at u re s

Confidential Medical Record When Signed

Provider 1 Provider 2 Receiving Provider

N ar ra ti ve

QA Review

Printed Name:

Signature:

HR Pa02 GCS

Gender

Intervention DoseBP

DOB

MM/DD/YYYY

PMH (Continued):

Vital Signs

Weight

Incident #:

Navy Fire & Emergency Services EMS Incident Report

NFIRS #::

D is p at ch

Department:

Incident Location:

Destination/Transferred to:

Responding Unit ID: Station:

Mutual Aid Units/Agencies:

FDID:

□ M □ F

V it al S ig n s / I n te rv en ti o n s

Resp

Pertinent Physical Exam Findings

Age

P h ys ic al E xa m

Patient's Name (Last, First, MI)

Date

MM/DD/YYYY

Page 1 of _____

D

M

Line Line

4 4

5 5

6 6

7 7

8 8

9 9

10 10

Dosage RouteTime BP HR Resp PaO2 GCS Intervention

Incident #:

NFIRS #:

Date: MM/DD/YYYY

InterventionsVital Signs

Navy Fire & Emergency Services EMS Incident Report

Provider

Use this Section to Attach EKG Strips

Narrative Continued From Page 1

Provider 2

Printed Name:

Signature:

Provider 1

Printed Name:

Signature:

Confidential Medical Record When Signed

____of____ □ Yes □ No

QA Review

Receiving Provider

Printed Name:

Signature:

Report Continued?

U.S. Navy Fire & Emergency Services Refusal of Care Form

Patient’s Name: _____________________________________________ Date: __________________

Incident #: ______________ Incident Location: ___________________________________________

Criteria for Refusing Care The patient meets all of the following:

□ Is an adult (18 or over), or if under 18 legally emancipated

□ Is oriented to Person, Place, Time, and Situation

□ Exhibits no evidence of:

Altered level of consciousness Alcohol or drug ingestion that impairs judgment

□ Understands the nature of their medical condition, the risks, and consequences of refusing care.

This form is being provided to me because I have: (check all that apply)

□ Refused Transport

□ Refused Medical Assessment

□ Refused Medical Treatment (check all that apply) □ IV Access □ Oxygen □ Physical Exam □ Spinal

Immobilization □ EKG Application □ Medications: _______________ Other: __________________

□ Insisted on being transported to a hospital other than the facility recommended by EMS providers

Acknowledgment of Information I have been offered an evaluation, medical care and/or transportation to a medical facility; however, I am refusing the services offered. I have been advised and understand the risks and consequences of refusing care/transport, including the fact that a delay in treatment and/or transport by means other than an ambulance could be hazardous to my health, and under certain circumstances, include disability and/or death.

Release of Liability By signing this form, I am releasing the U. S. Navy Fire & Emergency Services and the on-line medical control physician (if contacted) of any liability or medical claims resulting from my decision to refuse the transport, medical assessment and treatment offered.

I have read and understand the “Acknowledgment of Information” and “Release of Liability”.

Patient Signature: __________________________________________________ □ Refused to sign

Relationship (if not the patient): Lawful: □ Parent □ Guardian □ Conservator (pertains to child or dependent only)

Patient Disposition Released in care of:

□ Self

□ Parent

□ Guardian

□ Law Enforcement

Agency: __________________________

Badge: ___________________________

□ Other: ____________________________

Instructions

1. If you change your mind or the patient’s condition changes:

a. Call the local emergency number,

b. Go to an emergency room in your area or

c. Call your private doctor.

2. Other: _______________________________

Form Completed by: ____________________________________ I.D. #: ______________________

Witness Signature: __________________________ Name (printed): _________________________

Address: __________________________________________________________________________

City: ____________________________State: ____ Zip: ________ Phone: (_____) _____________