HomeMy WebLinkAbout106.004 - EMS-13, First Responder Pre-Hospital Care Report Worksheet
ADMINISTRATIVE MANUAL
FORMS
106.004 FRESNO COUNTY FIRST RESPONDER PRE-
HOSPITAL CARE REPORT WORKSHEET
(EMS-13)
EFFECTIVE: JUNE 2008
Current Revision Date: 9/19/19 Next Revision Date: 9/19/22
Author’s Name/Rank:
Jonathan Lopez-Galvan,
Firefighter Specialist Review Level: 1
Administrative Support:
Leslie Oulashian,
Management Analyst II
PURPOSE
The following form can be used to document patient care provided in a pre-hospital
setting.
APPLICATION
This form is meant to be a worksheet for documentation of patient care. The use of
this form is not required.
OPERATIONAL POLICY
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OPERATIONAL GUIDELINE
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PROCESS
Submit the completed form at the end of the shift the incident occurred on.
Initiation of this form occurs when:
1. Responding to medical-aid calls where an AED is used.
2. Refusal of medical care and transportation (RMCT) where an
ambulance is canceled prior to scene arrival.
Section 106.004
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3. Confirmed deceased (11-44) where an ambulance is canceled prior to
scene arrival.
INFORMATION
The form has not been updated to reflect new CCEMSA policies for CPR ratios and
defibrillation sequences. Refer to CCEMSA Policy No. 510.08, Cardiac Arrest-
Medical for updated protocols.
DEFINITIONS
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CROSS-REFERENCES
Central California Emergency Medical Services Agency (CCEMSA)
BLS Treatment Protocol 510.08 (Cardiac Arrest – Medical)
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EMS-13
FIRST RESPONDER
PREHOSPITAL CARE REPORT Date
FRESNO / KINGS / MADERA EMS #
EMERGENCY MEDICAL
SERVICES Fire Incident #
Patient Name: Gender:
Male
Female
Age:
Years
Months
Days
Unit:
Patient Address: Arrive:
Location of Incident: DOB: Weight: Pt Contact:
Chief Complaint Cardiac Arrest Information
Pulseless/Non-Breathing GCS LOC X Witnessed: Public Police Rescuer None
Complaint: CPR Started: Public Police Rescuer None
P Down Time to CPR: CPR Started:
Q Treatment Defibrillation
R
Time S R/S
W/S Pulse CPR
Inil.
S 200 360 Y N 1 Min.
T
Vital Signs
Time Resp H/P Pulse Cap Refill Pupils Skin
Past Medical History Denied
Unknown Cardiac (Unspecific)
MI Psych CHF
Angina COPD CVA
Hypertension
Diabetes GI
Cancer
Seizures Pacemaker Patient Outcome RAS 1144
Patient Refused Evaluation Code Called At Scene
Medications Denied BLS Therapy
Unknown O2 N/C Mask DV BVM Time:
Liters 2 6 15
Allergies Denied Airway OPA NPA Suction
Unknown Hemorrhage Control Splint
Physical WNL ABN Spine Immobilization Oral Glucose
Heart DNR: Form Time Term. CPR:
Neck Medallion Medical Trauma
Back Init. Team Members Cert No.
Chest
Abdomen
Pelvic
Extremities Transfer to Ambulance Transport
Unit No.
Neuro Signature:
PATIENT COPY
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EMS-13
Section 106.004
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