EMS FIELD REPORT

EMS FIELD REPORT
Date
MonthDayYear
DateHourMinutes
CALL LOCATION
NATURE OF CALL
INCIDENT TYPE
APPARATUS
PERSONNEL ON SCENE
Other
MUTUAL AID GIVEN TO
GIVEN TO
MUTUAL AID RECEIVED
RECIEVED FROM
AMBULANCE

PATIENT INFORMATION
PATIENT NAME
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Area CodePhone Number
DOB
MonthDayYear
Date
PRIMARY PHYSICIAN
SEX

PATIENT ASSESSMENT
CHIEF COMPLAINT
PATIENT CONDITION
MEDICAL HISTORY
ALLERGIES
MEDICATIONS
SKIN CONDITION
PUPILS
SUSPECTED TRAUMA
TRAUMA CAUSE
Other
VEHICULAR CAUSE
Other
SAFETY EQUIPMENT USED
Other
ENVIROMENTAL CAUSES
Other

VITAL SIGNS
TIME
:HourMinutes
HEART RATE
BLOOD PRESSURE
SPO2 %
RESP. RATE
RESPIRATION QUALITY
LEFT LUNG SOUNDS
RIGHT LUNG SOUNDS
TIME
:HourMinutes
HEART RATE
BLOOD PRESSURE
SPO2 %
RESP. RATE
RESPIRATION QUALITY
LEFT LUNG SOUNDS
RIGHT LUNG SOUNDS
TIME
:HourMinutes
HEART RATE
BLOOD PRESSURE
SPO2 %
RESP. RATE
RESPIRATION QUALITY
LEFT LUNG SOUNDS
RIGHT LUNG SOUNDS

TREATMENT
GLASGOW SUMMARY
Rows EYE OPENING VERBAL RESPONSE MOTOR RESPONSE
SCALE VALUE
MEDICATIONS
OXYGEN THERAPY
AED USE
:HourMinutes
NUMBER OF SHOCKS ADVISED
EXPOSURE

NARRATIVE
NARRATIVE
REPORTED BY
First NameLast Name
PSID
Signature
Clear
Date
MonthDayYear
DateHourMinutes
Should be Empty: