GENERIC RUN REPORT
Prehospital Patient Care Chart
INCIDENT NUMBER UNIT ID INCIDENT DATE
INCIDENT ADDRESS INCIDENT CITY INCIDENT STATE INCIDENT ZIP CODE
INCIDENT COUNTY INCIDENT LOCATION TYPE
COMPLAINT REPORTED BY DISPATCH EMERGENCY MEDICAL DISPATCH PERFORMED
No Yes w/pre-arrival instructions
Yes w/out pre-arrival instructions
INCIDENT/PATIENT DISPOSITION
Treated, Transport EMS No Patient Found Treated, Transferred care Treated, Transported Law Enforcement
Cancelled No Treatment Required Pt Refused Care
Treated & Released Dead at Scene Treated, Transported Private Vehicle
LEVEL OF SERVICE
BLS, Emergency
ALS, Level 1 Emergency
ALS, Level 2
Specialty Care Transport
Helicopter
Not Applicable
NUMBER OF PATIENTS ON SCENE
Single None
Multiple
MASS CASUALTY
Yes
No
TYPE OF SERVICE REQUESTED
Scene Response ED to ED Transfer
Mutual Aid Intercept
PRIMARY ROLE OF THE UNIT
Transport Non-transport
Supervisor Rescue
TYPE OF DELAY (S)
DISPATCHER
None-N/A
Not known
Caller Uncooperative
High Call Volume
Language Barrier
Location (Inability to obtain)
No Unit Available
Safety Conditions
Technical Failure
Other
RESPONSE
None-N/A
Crowd
Directions
Distance
Diversion
Hazmat
Safety Conditions
Staff Delay
Traffic
Ambulance Crash
Ambulance Failure
Weather
Other
SCENE
None-N/A
Crowd
Directions
Distance
Diversion
Extrication>20 Min
Hazmat
Language Barrier
Safety Conditions
Staff Delay
Traffic
Ambulance Crash
Ambulance Failure
Weather
Other
TRANSPORT
None-N/A
Crowd
Directions
Distance
Diversion
Hazmat
Safety Conditions
Staff Delay
Traffic
Ambulance Crash
Ambulance Failure
Weather
Other
RETURN
None-N/A
Clean up
Decontamination
Documentation
ED Overcrowding
Equipment Failure
Equipment Replenishment
Other
Staff Delay
Ambulance Failure
AGE DATE OF BIRTH GENDER
Female Male
RACE ETHNICITY
CURRENT MEDICATIONS ALLERGIES PERTINENT HISTORY
INJURY PRESENT
Yes
No
CAUSE OF INJURY TYPE OF INJURY
Blunt Penetrating
Burn Not Known
ALCOHOL/DRUG USE INDICATORS
None Pt admits to drug use
Smell of alcohol on breath Pt admits to alcohol use
Alcohol and/or drug paraphernalia at scene
CHIEF COMPLAINT
CHIEF COMPLAINT ANATOMIC LOCATION
Abdomen Extremity Lower General/Global
Chest Back Extremity Upper
Head Neck Genitalia
CHIEF COMPLAINT ORGAN SYSTEM
CNS/Neuro OB/GYN Pulmonary Endocrine/Metabolic
Global Renal Cardiovascular Gastrointestinal
Psych Skin Musculoskeletal
CARDIAC ARREST
Yes, Prior to Arrival
Yes, After Arrival
No
RESUSCITATION
Defibrillation None-DOA
Ventilation None-DNR
Chest Compressions None-Signs of life
CAUSE OF CARDIAC ARREST
Presumed Cardiac Respiratory
Trauma Electrocution
Drowning Other
USE OF SAFETY EQUIPMENT
N/A Lap Belt Shoulder Belt Protective Clothing
Not Known Helmet Worn Protective Non-Clothing Gear Other
Child Restraint Eye Protection Personal Floatation Device None
AIRBAG DEPLOYMENT
None Present Deployed Front
Not Deployed Deployed Side
Deployed Other N/A
BARRIERS TO STANDARD PATIENT CARE
Development Impaired Physically Impaired Unattended/Unsupervised Hearing Impaired
Physical Restraint Unconscious Language Speech Impaired
Initial Call for Help Unit Left Scene
Unit Notified Patient arrived at Destination
Unit En Route Incident Completed
Arrive on Scene Available for Next Incident
RESPONSE MODE TRANSPORT MODE
Lights/Sirens
No Lights/No Sirens
Initial Lights/Sirens Downgraded to no Lights/Sirens
Initial No Lights/Sirens Upgraded to Lights/Sirens
Arrived at PT.
PRIOR AID
PRIOR AID OUTCOME
Improved Unchanged Worse Unknown
PERFORMED BY MEDICATIONS/ PROCEDURES PERFORMED BY MEDICATIONS/PROCEDURES
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