Transported as ALS

Disposition Code:
Destination (Hospital/Non-Hospital)

Proximity: In Area Out Of Area

Purpose:

Ambulance Requested By:

Type of Transport:
Weight of Patient:
Purpose of Round Trip:
Reason for Stretcher:

Transportation

Moved to ambulance on stretcher/backboard
Moved to ambulance on stair chair
Moved to ambulance on scoop
Carried to ambulance
Walked to ambulance
Met at ambulance
Restrained during transportation
In shock during transportation

Transported in Trendelenburg position
Transported in left lateral recumbent position
Transported with head elevated
Transported in position of comfort
Transported in prone position
Transported in sitting position
Transported in supine position
Other:

Patient bed confined before transport
Patient bed confined after transport
Patient moved by stretcher
Patient unconscious or in shock
Patient required physical restraints
Patient visibly hemorrhaging
Transport was medically necessary

Facility Transport:
Nearest Facility
For the benefit of the preferred provider
For the nearness of family
Equipment or specialist not available at 1^st facility

Hospital to Hospital transports:
Patient was discharged from 1^st hospital
Patient admitted to facility
Transported to nearest facility

Names of Crew

In Charge:	Driver:	Other:	Other:
EMT AEMT# #	CFR EMT AEMT# #	CFR EMT AEMT# #	CFR EMT AEMT# #