EMS Demo One

D i s p a t c h

Date

Run ID:

Veh. ID

Mileage
Begin
End
Total	0

Agency Name

Location

Dispatch Info

L.Code

Call Loc. [GPS]

L.Type

Cross Street

Care In Progress

None Citizen PD/FD PAD Used

Other First Responder Other EMS Phys

Call Received	On Route	At Scene	From Scene	At Destination	In Service	In Quarters

Call Received As: Num. of Patients:

Dispatch Method:

D e m o g r a p h i c s

1	2	3	4	5	6	7	8	9	10
First Name			MI		Last Name
Address [Same]
Apt/Unit #				Phone#1			Phone#2
City				State			Zip
DOB		Age		Gender			SS#
Emergency Contact							Phone#
Physician Contact							Phone#

Insurance Information

Primary Insurance Policy	Secondary Insurance Policy

Company: Address: Phone: Group#: Policy: Policy Holder: SS#: DOB: Medicare#: Medicaid#: Claim#:	Company: Address: Phone: Group#: Policy: Policy Holder: SS#: DOB: Medicare#: Medicaid#: Claim#:

P r e s e n t i n g P r o b l e m

Trauma

ALS On Scene

Chief Complaint - Trauma:

Chief Complaint - Medical:

Past Medical History

None Hypertension Seizures Stroke Diabetes COPD Cardiac Asthma

Medications:

Allergy to: Other:

Vital Signs [add][drop]

Time	Respiration	Pulse/BP	Level of Conscousness	Pupils	Skin	Status
: [Now]	Rate: Regular Shallow Labored SP02:	Rate: Regular Irregular BP:/	Alert Voice Pain Unresponsive	Right Left Normal Dilated Constricted Sluggish No Reaction	Unremarkable Cool Pale Warm Cyanotic Moist Flushed Dry Jaund.	C U P S

T r e a t m e n t G i v e n

Treatment Given [Meds]

Medication Info [close]

�	Medications	Dosage Options						IV Fluids
2	Narcan (Naloxone)	2mg						Normal Saline (NS 0.9%)
3	Valium (Diazepam)	5mg	6mg	7mg	8mg	9mg	10mg	D5W
4	Versed (Midazolam)	1mg	2mg	10mgIM				Ringers Lactate
5	Etomidate	.3mg/kg
6�	Vasopressin	40 U						IV catheter guage
7	Epi 1:1000	0.3mg	2mg (ET)					8g
8	Epi 1:10,000	1mg						10g
9	Epi Drip	1ug/min	2ug/min	3ug/min	4ug/min			14g
10	Amiodarone	300mg	150mg					16g
11	Sodium Bicarb	44meq	88meq
12	Magnisium Sulfate	2gm						20g
13	Calcium Chloride (CaCl2)	1gm						22g
14	Atropine Sulfate	0.5mg	1mg					24g
15	NTG (nitroglycerin) Tablets	1/150gr.
16�	NTG (nitroglycerin) Spray	0.4mg						Positions
17	Lidocaine	1.5mg/kg	75mg/kg					Standing
18	Lidocaine Drip	1mg/min	2mg/min	3mg/min	4mg/min			Sitting
19	Dopamine							Supine
20	Adenosine	6mg	12mg					Prone
21	Cardizem (Diltiazem)	0.25mg/kg						Left Latarel Recumbant
22	Lasix (Furosemide)
23�	Morphine Sulfate	2mg	3mg	4mg	5mg
24�	Albuterol Sulfate	00.08%
25�	Metaproterenol	05%
26�	Solumedrol (Methylprednisolone)	125mg
27�	Decadron (Dexamethazone)	12mg
28�	Benadryl (Diphenhydramine)	50mg
29�	Dextrose	25gm
30�	Thiamine	100mg
31�	Ativan (Lorazepam)	2mg
32�	Tetracaine (Proparacaine Hcl) 0.5%	1gtt	2gtt
33�	Oxytocin (Pitocin)	20U

D i s p o s i t i o n

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# #

N a r r a t i v e N o t e s

Signature:

I hereby refuse emergency medical treatment and/or transportation to the nearest emergency medical facility. I acknowledge that such treatment was advised by the ambulance technician or physician. I hereby release such persons from liability for respecting my wishes and following my express directions.

Por la presente se niegan tratamiento médico de emergencia y / o transporte a la instalación médica de emergencia más cercana. Reconozco que ese tratamiento fue aconsejado por el técnico de ambulancia o médico. Por la presente, la liberación de esas personas de la responsabilidad por el respeto de mis deseos y mis expresar siguientes direcciones.

Настоящим отказать чрезвычайной медицинской помощи и / или транспортировку до ближайшего аварийного медицинское учреждение. Я признаю, что такое обращение было сообщено на скорой помощи техник или врач. Настоящим освободить таких лиц от ответственности за соблюдение моих пожеланий и после моей выразить направлениях.

أقدم هنا رفض العلاج الطبي في حالات الطوارئ و / او النقل الى اقرب مرفق طبي للطوارئ. اني اعترف ان هذه المعامله ينصح بها الطبيب او فني اسعاف. أقدم هنا الافراج عن هؤلاء الاشخاص من المسؤولية عن احترام امنياتي والتعبير عن الاتجاهات التالية بلادي.

Io qui rifiutare il trattamento medico di emergenza e / o il trasporto alla più vicina struttura medica di emergenza. Riconosco che tale trattamento è stato consigliato dal medico o tecnico ambulanza. Con la presente versione da tali persone responsabilità per il rispetto e la mia voglia esprimere la mia seguenti direzioni.

I decide recusar tratamento médico de urgência e / ou de transporte para o médico de urgência mais próximo facilidade. Reconheço que tal tratamento foi advertido pela ambulância técnico ou médico. I decide libertar essas pessoas de responsabilidade por respeitando meus desejos e expressar a minha seguintes direções.

Ik weiger dringende medische behandeling en / of vervoer naar de dichtstbijzijnde medische faciliteit. Ik erken dat een dergelijke behandeling is geadviseerd door de ambulance technicus of arts. Ik vrijlating van deze personen van de aansprakelijkheid voor het respecteren van mijn wensen en na mijn uitdrukkelijke richtingen.

Ich hiermit verweigern Notfall medizinische Behandlung und / oder den Transport zum nächstgelegenen Notfall medizinische Einrichtung. Ich anerkenne, dass sich eine solche Behandlung empfohlen wurde von der Ambulanz Techniker oder Arzt. Ich hiermit die solche Personen von der Haftung für die Einhaltung meine Wünsche und meine ausdrückliche folgenden Richtungen.

Patient Signature:

A u t h o r i z a t i o n

I request that payment of authorized Medicare, Medicaid, or any other insurance benefits be made on my behalf to Senior Care EMS for any services provided to me by Senior Care now or in the future. I understand that I am financially responsible for the services provided to me by Senior Care MES regardless of my insurance coverage, and in some cases, may be responsible for an amount in addition to that which was paid by my insurance. I agree to immediately remit to Senior Care EMS amy payments that I receive directly from insurance or any source whatsoever for the services provided to me and I assign all rights to such payments to Senior Care EMS. I authorize Senior Care EMS to to appeal payment denials or other adverse decisions on my behalf without further authorization. I authorize and direct any holder of medical information or documentation about me to release such information to Senior Care EMS and its billing agents, and/or the Centers for Medicare andMedicaid Services and its carriers and agents, and/or any other payers or insurers as may be necessary to determine these or other benefits payable for any services provided to me by Senior Care EMS, now or in the future. A copy of this form is as valid as an original.

Privacy Practices Acknowledgment: by signing below, I acknowledge that I have received Senior Care EMS Notice of Privacy Practices.

SIGNATURE SECTION: One of the following three sections MUST be completed.

SECTION I - PATIENT SIGNATURE

The patient must sign here unless the patient is physically or mentally incapable of signing:

Patient Signature or Mark:

If the patient signs with an "X" or other mark, it is recommended that someone sign below as a witness:

Witness Signature:

Witness Printed Name:

If patient is physically or mentally incapable of signing, Section II must be completed.

SECTION II - AUTHORIZED REPRESENTATIVE SIGNATURE

Complete this section only if patient is physically or mentally incapable of signing.

Reason the patient is physically or mentally incapable of signing:

Authorized representatives include only the following individuals (check one):

Patient's Legal Guardian Patient's Health Care Power of Attorney
Relative or other person who receives government benefits on behalf of patient
Relative or other person who arranges treatment or handles the patient's affairs
Representative of an agency or institution that furnished care, services or assistance to the patient.

I am signing on behalf of the patient. I recognize that signing on behalf of the patient is not an acceptance of financial responsibility for the services rendered.

Representative's Signature:

Representatives Printed Name:

SECTION III - EMERGENCIES ONLY - AMBULANCE CREW AND FACILITY REPRESENTATIVE SIGNATURES

Complete this section only for emergency ambulance transports, if patient was physically or mentally incapable of signing, and no authorized representative (as listed in Section II) was available or willing to sign on behalf of the patient at the time of service.

A. Ambulance Crew Member Statement (must be completed by crew member at time of transport)

My signature below indicates that, at the time of service, the patient named above was physically or mentally incapable of signing, and that none of the authorized representatives listed in Section II of this form were available or willing to sign on the patient's behalf.

Reason patient incapable of signing: Name and Location of Receiving Facility:
Time at Receiving Facility:

Signature of Crewmember:

Printed Name of Crewmember:

B. Receiving Facility Representative Signature

The above-named patient was received by this facility at the date and time indicated above.

Signature of Receiving Facility Representative:

Printed Name of Receiving Facility Representative:

C. Secondary Documentation

If no facility representative signature is obtained, the ambulance crew should attempt to obtain one or more of the following forms of documentation from the receiving facility that indicates that the patient was transported to that facility by ambulance on the date and time indicated above. The release of this information by the hospital to the ambulance service is expressly permitted by Section 164.506(c) of HIPAA.

Patient Care Report (signed by representative of facility) Facility Face Sheet/Admissions Record
Patient Medical Record Hospital Log or Other Similar Facility Record