EMS FIELD REPORT
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Minutes
CALL LOCATION
NATURE OF CALL
INCIDENT TYPE
EMS
STRUCTURE FIRE
VEHICLE FIRE
WILDLAND FIRE
OUTSIDE FIRE
OTHER FIRE
MVA INJURY
MVA NON INJURY
MVA UNKNOWN
FALSE ALARM
FIRE ALARM
ODOR DETECTION
HAZ MAT
PUBLIC SERVICE
RESCUE
OTHER
APPARATUS
ENGINE 151
ENGINE 152
TANKER 151
TANKER 152
RESCUE 151
RESCUE 152
SUPPORT 15
UTV 15
POV
PERSONNEL ON SCENE
1501
1502
1503
1504
1505
1506
1507
1508
1509
1510
1511
1512
1513
1514
1515
1516
1517
1518
1519
1520
1521
1522
1523
1524
1525
Other
MUTUAL AID GIVEN TO
BEDFORD
HURON
INDIAN CRK
MARION
MARSHALL
MITCHELL
OOLITIC
PERRY
SHAWSWICK
WILLIAMS
MONROE FIRE DIST
OWEN TWP
PERSHING TWP
CARR TWP
GIVEN TO
MUTUAL AID RECEIVED
BEDFORD
HURON
INDIAN CRK
MARION
MARSHALL
MITCHELL
OOLITIC
PERRY
SHAWSWICK
WILLIAMS
MONROE FIRE DIST
OWEN TWP
PERSHING TWP
CARR TWP
RECIEVED FROM
AMBULANCE
STAT FLIGHT
AIR EVAC
IU LIFE LINE
OTHER AIR
AMR
IU HEALTH
JACKSON CO EMS
OTHER GROUND
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PATIENT INFORMATION
PATIENT NAME
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
DOB
/
Month
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Day
Year
Date
PRIMARY PHYSICIAN
SEX
MALE
FEMALE
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PATIENT ASSESSMENT
CHIEF COMPLAINT
PATIENT CONDITION
STABLE
UNSTABLE
DOA
MEDICAL HISTORY
NONE
ALZHEIMER
ANGINA
ASTHMA
BEHAVIOR PROB
CANCER
COPD
CVA
CHF
DIABETES
HYPERTENSION
HYPOTENSION
KIDNEY DISEASE
MI
RENAL FAILURE
SEIZURES
SUBSTANCE ABUSE
THYROID
UTI
OTHER
ALLERGIES
MEDICATIONS
SKIN CONDITION
WARM
COOL
HOT
COLD
DRY
MOIST
DIAPHORETIC
CLAMMY
NORMAL TONE
PALE
CYANOTIC
FLUSHED
ASHEN
MOTTLED
PUPILS
PERRL
UNEQUAL
CONSTRICTED
DILATED
UNRESPONSIVE
SUSPECTED TRAUMA
AIRWAY
BLEEDING
BURNS
EJECTED
FRACTURE
HEAD INJURY
MULTI-TRAUMA
SPINAL
TRAUMA CAUSE
BLUNT
ELECTRICAL
FALL
GUNSHOT
MACHINE
MVA
SHARP OBJECT
WATER ACCIDENT
Other
VEHICULAR CAUSE
AIRCRAFT
ATV/ UTV
AUTOMOBILE
BICYCLE
MOTORCYCLE
WATERCRAFT
FARM
INDUSTRIAL
Other
SAFETY EQUIPMENT USED
AIRBAG
SEATBELT
OTHER RESTRAINT
HELMET
SAFTY BELT
Other
ENVIROMENTAL CAUSES
CHEMICAL BURN
COLD RELATED
ELECTRICAL
HAZMAT
HEAT RELATED
NEAR DROWNING
STING
BITE
THERMAL BURN
Other
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VITAL SIGNS
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HEART RATE
BLOOD PRESSURE
SPO2 %
RESP. RATE
RESPIRATION QUALITY
NORMAL
SHALLOW
DEEP
ABSENT
LABORED
FATIGUED
NOT ASSESSED
UNKNOWN
LEFT LUNG SOUNDS
ABSENT
CLEAR
RALES (SHORT CRACK)
RHONCHI (SNORING)
STRIDOR (LOUD HI-PITCH)
WHEEZES
RIGHT LUNG SOUNDS
ABSENT
CLEAR
RALES (SHORT CRACK)
RHONCHI (SNORING)
STRIDOR (LOUD HI-PITCH)
WHEEZES
TIME
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Hour
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20
30
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Minutes
HEART RATE
BLOOD PRESSURE
SPO2 %
RESP. RATE
RESPIRATION QUALITY
NORMAL
SHALLOW
DEEP
ABSENT
LABORED
FATIGUED
NOT ASSESSED
UNKNOWN
LEFT LUNG SOUNDS
ABSENT
CLEAR
RALES (SHORT CRACK)
RHONCHI (SNORING)
STRIDOR (LOUD HI-PITCH)
WHEEZES
RIGHT LUNG SOUNDS
ABSENT
CLEAR
RALES (SHORT CRACK)
RHONCHI (SNORING)
STRIDOR (LOUD HI-PITCH)
WHEEZES
TIME
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Hour
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20
30
40
50
Minutes
HEART RATE
BLOOD PRESSURE
SPO2 %
RESP. RATE
RESPIRATION QUALITY
NORMAL
SHALLOW
DEEP
ABSENT
LABORED
FATIGUED
NOT ASSESSED
UNKNOWN
LEFT LUNG SOUNDS
ABSENT
CLEAR
RALES (SHORT CRACK)
RHONCHI (SNORING)
STRIDOR (LOUD HI-PITCH)
WHEEZES
RIGHT LUNG SOUNDS
ABSENT
CLEAR
RALES (SHORT CRACK)
RHONCHI (SNORING)
STRIDOR (LOUD HI-PITCH)
WHEEZES
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TREATMENT
GLASGOW SUMMARY
EYE OPENING
VERBAL RESPONSE
MOTOR RESPONSE
SCALE VALUE
MEDICATIONS
BABY ASPIRIN LOW DOSE 81MG X4
ORAL GLUCOSE
(PT'S) NITROGLYCERIN
EPI AUTO INJECTOR
NARCAN
OXYGEN THERAPY
NASAL CANULA
BVM
NON RE-BREATHER
AED USE
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NUMBER OF SHOCKS ADVISED
EXPOSURE
YES
NO
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NARRATIVE
NARRATIVE
REPORTED BY
First Name
Last Name
PSID
Signature
*
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