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SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 1 of 18 A. PURPOSE: To comply with Article VI, Rule 6.01, Data Collection Plans, of Pre-hospital Medical Services Act: Chapter 1ll 1/2, Para, 410 et seg. Illinois Revised Statutes, as amended by Public Act 81-922. B. 1. 2. 3. 4. 5. 6. POLICY: The Southern Fox Valley EMS System will collect data according to specifications set forth in the Emergency Medical Data Collection System record keeping system. Data will be collected and maintained by the EMS Medical Director or his designee in the form of written EMS record copies filed with the SFVEMS system office and/or Computerized. A copy of the SFVEMS system record shall be filed with the receiving hospital on each patient transported to the facility for inclusion in the patient’s permanent medical record. All non-transport vehicle providers shall document all medical care provided and shall submit the documentation to the EMS system within 24 hours. The Resource Hospital shall review all medical care provided by non-transport vehicles and shall provide a report to the Department upon request. All refusals and or other paperwork pertaining to the incident and or patient shall be scanned and uploaded /attached to the computer report for that incident. The ambulance provider shall submit the run report data to the Resource Hospital. Each Resource hospital shall submit a data report to IDPH on March 1, June 1, September 1, and December 1 of each year covering run report data from the preceding quarter. C. PROCEDURE: Listed below is the proper procedure for filling out the SFVEMS Patient Care Report in the ESO Solutions reporting software. This report should be completed prior to leaving the receiving facility and within 24 hours of a non transport incident. SOUTHERN FOX VALLEY EMS SYSTEM ESO SOLUTIONS PATIENT CARE REPORT DATA ENTRY DICTIONARY FINISHING A REPORT WHEN YOU ARE DONE WITH YOUR REPORT YOU NEED TO VALIDATE AND LOCK THE REPORT. Validating: When you feel you are done with your report hit the validate button at the top of the page. You will get a message that says validation is complete, you can then lock the report by hitting the lock button (next to validate). If the report is not complete, you will get a list of items that need to be completed to validate the report. Click on the item and it will take you to the area that needs to be completed. Once this is done and validation is complete, hit the lock button. Locking: Once the report is complete, hit the lock button, the validation process will run and if the report is not validated it will give you the message of what needs to be completed before the report can be locked. NOTE: If you have multiple patients it will default to patient 1 in the validation process. Print: select the print button on the home page, once that page comes up, select the pdf view button on the top of the page and then select print. SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 2 of 18 Fax: On the home page, select the fax button; a fax number will appear and you would need to okay the fax process. This function is to be used when there is no printer attached to the computer you are using. The fax numbers can be used at any time and are pre programmed for the destination you chose in the patient disposition area. Email: On the home page, select the email button, the email address is pre populated to a specific email address of the receiving facility. Example: Rush Copley – Jack Taxis Cancel / Continue When you attempt to navigate from a page that you have made changes to, you will see a box that states the following: Are you sure you want to navigate away from this page? Any unsaved changes will be lost. Press OK to continue – you will lose your data Press cancel to stay on the current page INCIDENT DETAILS PAGE: 1. CALL DATE 2. INCIDENT NUMBER – The incident number assigned by the your Dispatch System INCIDENT DETAILS 3. RUN TYPE - The type of service or category of service requested of the EMS service responding to the specific EMS incident a. 911 call b. Emergency Transfer c. Non Emergency Transfer d. Standby e. Mutual Aid f. Intercept 4. MUTUAL AID – select a reason for your mutual aid response a. Additional Ambulances Needed b. Disaster response c. Other d. Rendezvous for equipment failure e. Rendezvous for level of care f. Rendezvous for patient pick up g. unknown 5. PRIORITY – Indication whether or not lights and/or sirens were used on the vehicle on the way to the scene a. No lights / sirens b. Lights / sirens c. Lights / sirens downgraded d. Lights / sirens upgraded 6. LEAD MEDIC – primary patient care giver 7. DRIVER – person who drives ambulance from scene to destination 8. MEDIC 3 – secondary patient care giver 9. MEDIC 4 – additional patient care giver 10. MEDIC UNIT / DISTRICT – select from a pre populated drop down box 11. VEHICLE – select from a specific pre populated drop down box SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 3 of 18 INCIDENT LOCATION 12. LOCATION TYPE – The kind of location where the incident happened a. Home b. Street or Highway c. Doctor’s office d. Nursing home e. Assisted Living Center f. Hospital E. R. g. Hospital - other or unspecified location h. Dialysis i. EMS provider j. Other specified space k. Rehabilitation Center 13. LOCATION NAME – fill in specific information for Location Type 14. LOCATION ADDRESS – The street address (or best approximation) where the patient was found, or, if no patient, the address to which the unit responded 15. ZIP CODE – the ZIP code of the incident location 16. ZONE – specific to responding unit / agency 17. CITY - The city or township (if applicable) where the patient was found or to which the unit responded (or best approximation) 18. COUNTY – The county or parish where the patient was found or to which the unit responded ( or best approximation) 19. STATE – The state, territory or province where the patient was found or to which the unit responded (or best approximation) INCIDENT TIMES / MILEAGE – the program automatically defaults to the current days date. If your incident spans two different dates you need to change the date for your entry. 20. CALL RECEIVED – The time the phone rings (911 call to public safety answering point or other designated entity) requesting EMS services 21. CALL DISPATCHED – The time the responding unit was notified by dispatch 22. ENROUTE - The time the unit responded: that is, time the vehicle started moving 23. ON SCENE – The time the responding unit arrived on the scene: that is the time the vehicle stopped moving 24. AT PATIENT – The time the responding unit arrived at the patient’s side 25. DEPART SCENE - The time the responding unit left the scene (vehicle started moving) 26. AT DESTINATION – The time the responding unit arrived with the patient at the destination or transfer point 27. INCIDENT CLOSE – The time the unit was back in service and available for response (finished the call, but not necessarily back in home location) (this will be the time you leave the hospital per SFVEMSS). If the report is completed at the hospital, the time you finish the report will be your incident close time. If you get another call while typing your report you would use the time you left the hospital for your incident closed time, when you finish your report. For a non transport, the incident closed time would be the time that you left the scene SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 4 of 18 28. ODOMETER READING – this is a mandatory field for some departments a. START – The mileage (odometer reading ) of the vehicle at the beginning of the call (when the wheels begin moving) b. AT SCENE – The mileage (odometer reading) of the vehicle when it arrives at the patient c. AT DESTINATION – The mileage (odometer reading) of the vehicle when it arrives at the patient’s destination d. END – The ending mileage (odometer reading) of the vehicle (at time back in service) e. LOADED MILES f. TOTAL – total number of miles for incident 29. AEROMEDICAL SERVICE CONTACTED – check box if helicopter activated (to be filled in anytime helicopter is activated) a. CONTACT TIME – time dispatch / scene talk to helicopter service requesting air response b. AT SCENE – time which helicopter / aeromedical unit arrives on the scene c. DEPART SCENE – time which helicopter / aeromedical unit departs the scene 30. DELAYED RESPONSE – The response delays, if any, of the unit associated with the patient encounter a. Traffic b. Weather c. Vehicle failure d. Vehicle crash e. Distance f. Directions g. Crowd h. Diversion i. Other j. Staging INCIDENT OUTCOME 31. DISPOSITION – Type of disposition treatment and/or transport of the patient A. TRANSPORT CODE 1 (Non-Emergency) B. TRANSPORT CODE 3 (Emergency) C. TREAT NO TRANSPORT – (Assessed/Treated/ No Transport) D. NO TREAT NO TRANSPORT – Pt Refused ALL Care and Assessment E. NO PATIENT FOUND – NO one PHYSICALLY there! F. FALSE ALARM (NO INCIDENT OCCURRED) (Accidental tone out) G. CALL CANCELLED – Other agency cancelled you enroute H. DEAD ON SCENE NO TRANSPORT I. DEAD ON SCENE TRANSPORT J. PATIENT CARE TRANSFERRED – BLS to ALS, BLS/ALS to Aeromedical K. DISREGARDED ENROUTE 32. Refusal Reason – if C or D in the above list are entered, you then need to select a Refusal Reason from the following drop down menu a. Against medical advice b. Patient to seek further care in POV c. Patient does not feel injury/illness requires ambulance d. Patient in custody of law enforcement e. Other SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 5 of 18 33. Transport due to - select from the following drop down menu – reason patient transported to the receiving facility. a. Patient b. Family c. Protocol d. Trauma triage e. Distance – closest facility f. Physician g. Diversion - when one hospital sends you to another facility (hospital on bypass) h. Other 34. Diverted from - if you choose item g in the transport due to box you will need to select a facility from the drop down box, to indicate who diverted the unit. 35. Transport to – drop down pre populated box 36. Requested by – who requested the ambulance for this incident a. Patient b. Family c. Bystander d. Physician e. NH staff f. Law enforcement g. Other 37. Treatment Level – level of care that patient received a. BLS b. ALS c. Critical Care DESTINATION INFORMATION 38. Critical Trauma Criteria Met: If your selection in Destination Type (35) is a Hospital ER you will need to fill in this area a. Level I b. Level II c. Level III d. No 39. Trauma System Activated a. Yes b. No c. N/A d. Unknown PATIENT INFORMATION PAGE 1. 2. 3. 4. 5. 6. 7. PATIENT DATA LAST NAME – The patient’s last (family) name FIRST NAME – Patient’s first (given) name MIDDLE INITIAL / NAME – The patient’s middle name, if any SSN – patient’s social security number DOB – patient’s date of birth (calendar picture will give you a date selector) AGE - will automatically populate if you put in DOB GENDER – Select Male or Female SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 6 of 18 RACE / ETHNICITY – The patient’s race as defined by the OMB (US Office of Management and Budget) a. American Indian/Alaskan Native b. Asian/ Pacific Islander c. Black d. Hispanic e. Other f. Unknown g. White / non Hispanic 9. Copy Incident Address – check this box if incident is at patients home address this will then populate the patient information address area 10. COUNTRY – Patient’s home Country – drop down menu 11. ADDRESS – The patient’s home mailing or street address 12. ZIP CODE - The patient’s home ZIP Code of residence 13. CITY – The patient’s home city or township or residence The looking glass next to boxes 12 and 13 will assist you in obtaining proper zip code for a city. If you look up one of the above items - selecting an item will populate the other box 14. COUNTY – The patient’s home county or parish or residence This box will also populate when selecting box 12 or 13 15. STATE – The patient’s home state, territory or province or District of Columbia, where patient resides 16. TELEPHONE – The patient’s home or primary telephone number 17. DRIVER’S LICENSE – The patient’s driver’s license number 18. DL STATE - The state that issued the patient’s driver’s license 8. ONCE THIS SECTION IS COMPLETE HIT THE SAVE BUTTON ON THE SCREEN Frequently seen patients can be selected if you have the patients name and social security number. This will populate the address, billing and past medical history / medication fields for you. This information will need to be verified to be correct before saving. Patients are saved for 6 months. After this information is saved, you can add any additional patients to the incident. Select the “Add New Patient” button (next to the SAVE button) and a new patient information screen will come up. The incident information page will be added to this patients report. You may need to go back and change the incident outcome information. To navigate between patients you go to the top of the page and select patients by using the forward and back arrows. If you have more than one ambulance on the scene they will each need to fill out information for their patients. MED HX /ALLERGIES/MEDS 19. MED HX/ALLERGIES/ MEDS – select one area at a time from the drop down menu of the three items below, you will then go to the TYPE area (20) for specific items a. Past History b. Allergy c. Present Medication SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 7 of 18 When selecting the following items, hit add after each entry and SAVE when you are done adding information. 20. TYPE – gives further information for each of the drop down boxes of item 19 o. Epilepsy Past History a. Denies p. Diabetes b. Other q. Gastro Intestinal problems c. Unknown r. Hypertension d. Angina s. Infectious disease e. Arrhythmias t. Myocardial Infarction f. Asthma u. Pacemaker / AICD g. Behavioral/psych disorder v. Pregnancy/OB h. Cancer Delivery/Complications i. Cardiac w. Renal Failure j. Cardiac arrest x. Seizures k. CHF y. Smoking l. COPD z. Stroke/CVA m. Coronary Artery Disease aa. Substance Abuse n. Dementia bb. Syncope Allergy a. NDKA b. Denies Present Medication c. Other a. Denies d. Acetaminophen b. Prescription e. Aspirin c. Non prescription f. Benzodiazepines d. Unknown g. Chemical e. List of common medications to h. Codeine select from i. Food Allergy j. Insect Sting k. Sulfonamides l. Latex m. Penicillin 21. MED/COMMENTS – enter any comments pertinent to patient care or history You can enter Prescription in the previous area and then write out the list in this section instead of selecting individual medications Select ADD as you are entering information, then hit SAVE to save all the entries PERSONAL ITEMS This section allows you to document the disposition of the patient’s personal items 22. PERSONAL ITEMS – a drop down lists of the patient’s personal items a. Cell phone / pager e. Other b. Jewelry f. Purse / wallet c. Keys g. Watch d. Medications SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 8 of 18 23. GIVEN TO – enter who items were given to by name or location 24. NOTES / OTHER – any notes about personal items that are pertinent SAVE THIS INFORMATION VITAL SIGNS PAGE 1. VITAL SIGNS – Go thru these steps for each set of vitals that are recorded for the patient a. Time / Date - time and date vitals were recorded b. AVPU Alert Voice Pain Unconscious c. Blood Pressure Systolic Diastolic Method Manual cuff Automatic cuff Palpated d. Pulse Rate enter number Rhythm Regular Irregular Absent Paced e. f. g. Respiration Rate enter number Rhythm Regular Irregular Ventilated Assisted Pulse Oximetry – enter the SP02 value oxygen End Tidal CO2 - enter EtCO2 value Strength Strong Weak Bounding Thready Absent Quality Non-labored Labored Shallow Absent Ventilated Assisted Check whether recorded on room air or while patient is on SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 9 of 18 GLASCOW COMA SCORE EYES – open to the following stimuli a. 4 – spontaneous b. 3 – to voice c. 2 – to pain d. 1 – none VERBAL – responds in one of the following verbal means a. 5 – oriented (smiles / babbles) b. 4 – confused (irritable/non consolable) c. 3 – inappropriate words (cries/screams with pain) d. 2 – incomprehensible sounds (grunts/moans with pain) e. 1 – none MOTOR – responds with one of the following motor actions a. 6 – obeys instructions (appropriate for age) b. 5 – localizes to pain (withdraws to touch) c. 4 – withdraws from pain (withdraws from painful stimuli) d. 3 – abnormal flexion (decorticate posturing) e. 2 – abnormal extension (decerebrate posturing) f. 1 – none Once this area is completed the program will automatically calculate the GCS and the Revised Trauma Score. REVISED TRAUMA SCORE This will automatically be calculated once you fill in the Glascow Coma Score area ECG 3 LEAD RHYTHM a. Agonal b. Artifact c. Asystole d. Atrial fibrillation/flutter e. AV Block – 1st degree f. AV Block – 2nd degree type 1 g. AV Block – 2nd degree type 2 h. AV Block – 3rd degree i. Junctional j. Normal Sinus Rhythm 12 LEAD INTERPRETATION – Enter YOUR interpretation of the 12 lead SUSPECTED MI – check this box for a suspected MI BLOOD GLUCOSE – enter the value PAIN SCALE (0-10) – select the appropriate or voiced value a. 0-1 no pain b. 2-3 mild pain c. 4-5 moderate pain k. l. m. n. o. p. q. r. s. t. Paced PEA Sinus Arrhythmia Sinus Bradycardia Sinus Tachycardia Supraventricular Tachycardia Torsades De Points Ventricular Tachycardia Ventricular Fibrillation Other d. e. f. 6-7 bad pain 8-9 very bad pain 10 unbearable pain TEMPERATURE – enter the patient’s temperature in F or C Hit the SAVE button and then enter additional sets of vital signs – you must enter SAVE between each set of vitals SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 10 of 18 FLOWCHART PAGE – This page contains documentation of treatments that the patient received. 1. TREATMENT TYPE – Select one of these choices and continue the following selections a. Airway – ALS b. Airway – BLS c. Defib/Cardio/Pace d. IV Therapy e. Medication f. Splint/Immob/Bandage g. Critical Care 2. 3. DATE TIME 4. INTERVENTION A. Airway – ALS a. Combitube b. King Airway c. Laryngeal Mask Airway d. Nasogastric Tube e. Nasotracheal Intubation f. Needle Cricothyroidotomy g. Orogastric Tube h. i. Orotracheal intubation Pleural Decompression j. Rapid Sequence Intubation (drug assisted intubation) k. Retrograde Intubation l. Surgical Cricothyroidotomy m. Ventilator B. Airway – BLS a. CPAP b. NPA – nasopharyngeal airway c. OPA – oropharyngeal airway d. Oxygen 1. NC – nasal cannula 2. NRB – non rebreather mask 3. BVM – bag valve mask 4. Pedi NC 5. Blow by 6. SFM – simple face mask 7. Venture e. Suction Once you select any airway intervention an Airway Complications box will pop up you then need to check one of the following if had any problems securing the airway Gag reflex Blood/vomit Clenched teeth Unable to visualize Anatomy SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 11 of 18 Once you enter your airway intervention you will need to fill in the following information Size Placed at ___ cm Successful yes / no Provider – drop down box of crew members on incident Oxygen – will ask you to fill in Flow Rate and Provider C. Defib/Cardio/Pace a. AED / Defib b. Cardiovert c. Manual Defib d. Pacing e. CPR f. Resqpod Once you select one of the procedures listed above, you will be asked to fill in the following: Energy Type Paced Rate – beats per minute Capture Yes No Provider D. IV THERAPY a. Blood draw f. Saline Lock b. IV w /LR (lactated g. IV w/D5W ringers) h. Central line c. LR bolus i. IV Monitoring d. IV w/ NS (normal j. Intraosseous saline) k. EZ-IO (adult) e. NS bolus l. EZ-IO (pedi) Once an IV Therapy intervention is selected you will need to fill in the following SIZE a. 14G f. 24G b. 16G g. Double lumen c. 18G h. Single lumen d. 20G i. Triple lumen e. 22G SITE a. L dorsal hand m. Sternal IO b. R dorsal hand n. Scalp c. L forearm o. Other d. R forearm p. Subclavian e. Left AC q. Umbilical f. Right AC r. Left subclavian g. Left External Jugular s. Right subclavian h. Right External Jugular t. Right tibia i. Left lower extremity u. Left tibia j. Right Lower extremity v. Right humerus k. Left Tibia IO w. Left humerus l. Right Tibia IO SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 12 of 18 You will also need to fill in the following boxes regarding the IV Therapy intervention Total Fluid Infused Successful yes no Provider E. MEDICATION DATE TIME INTERVENTION DROP DOWN LIST OF DRUGS DOSE MEASURE – This box will change to appropriate measure when you select a drug from the drop down list 1. Grams 6. units 2. Inches 7. self 3. IU 8. sprays 4. mEq 9. mcg/min 5. ml 10. mg/kg ROUTE 1. Intravenous 2. Intramuscular 3. Intraosseous PT. RESPONSE 1. Unchanged 2. Improved 3. Worse 4. Not applicable Provider – who performed the intervention After each intervention entry you need to click on the ADD button When you are done entering all your interventions, you need to click on the SAVE button to make your entries permanent. FIRST RESPONDER AID TYPE – Any care done for the patient prior to your arrival needs to be documented in this section This section can also be used when two separate departments respond to an incident – Dept. A responds with an engine and starts treatment, Dept. B responds with an ambulance and transport. Documentation of Dept. A’s care would go in this section. A. Aid Prior to Arrival – By a. First Responder b. Law Enforcement c. Nursing Home Staff d. Physician on Scene e. Healthcare Provider on Scene f. Bystander g. Not applicable h. Other i. Unknown SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 13 of 18 Aid Prior to Arrival – Type a. AED only k. OPA – oropharyngeal b. Bandaging airway c. Bleeding Control l. Other d. C-collar m. Oxygen via BVM e. CID – Cervical n. Oxygen via NC Immobilization Device o. Oxygen via NRB f. CPR p. Spinal Immobilization g. CPR and AED q. Splinting h. MAST / PASG r. Suction i. Medication s. Traction Splint j. NPA – nasopharyngeal t. Ventilatory Support airway C. Patient Response a. Unchanged b. Improved c. Worse d. Not known e. Not applicable D. Comments – you will need to enter any medications given in this box or any other pertinent information regarding care prior to your arrival B. SAVE your entries ASSESSMENT PAGE ASSESSMENT DETAILS BOX - This box will be populated after you go thru the selection process of the remainder of the screen. NOTE: IF “NO ABNORMALITIES” IS SELECTED YOU ARE SAYING THAT ALL LISTED ABNORMALITIES HAVE BEEN ASSESSED AND FOUND NOT TO BE PRESENT **The program defaults to Not Assessed. ** If no abnormalities or not assessed is checked then you do not need to check any other box – this applies to all of the assessment sections MENTAL STATUS No Abnormalities Not Assessed Combative Confused Hallucinations Unresponsive other NOT Oriented to - (check box) person place time Comments event SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 14 of 18 ANATOMICAL PICTURE – Click to enlarge the anatomical picture – Anterior or Posterior You can navigate between anterior and posterior view once you enlarge the picture Click on the injury type – take your mouse and click on the anatomical part that has the injury a red box with the injury listed will appear on the picture. To delete or change an injury location, Click on the red injury indicator to change it to blue – this puts you into edit mode. To reposition and injury – (you must have a blue injury indicator box) simple move your mouse to the new location and click the area. The injury indicator box will then turn Red. To delete an injury click on the red box to make it blue, then click on the delete button at the top of the page. The injury is then removed. Close the anatomical picture and your injury information will be entered into the assessment box. SKIN – select No abnormalities Not assessed Hot Cool Diaphoresis Lividity Comments Pale Cyanotic Jaundiced Other Mottled HEENT – (Head, Ears, Eyes, Nose Throat) No abnormalities Not assessed Head/Face Facial droop Dysconjugate gaze – eyes not tracking together CSF – cerebral spinal fluid Drainage Battles Sign Mass / Lesion Other Eye Left - dilated constricted non reactive blind other pupil size Eye Right 2 mm 3 mm 4 mm 5 mm 6 mm 7 mm Neck - JVD Tracheal Deviation Stridor Subcutaneous air Other Comments CHEST No abnormalities Not assessed Chest - Accessory Muscle Usage Retractions Other SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 15 of 18 Lung Sounds Decreased LU Wheezing LU Rales LU Rhonchi LU LL Other LU Heart Sounds Decreased sounds Murmur Other Comments LL LL LL RU LL RU RU RU RL RU RU RU RU RU RL RL RL RL BACK No abnormalities Not assessed Back Deformity Atraumatic pain Scoliosis Other Comments ABDOMEN No abnormalities Not assessed Tenderness LU Distention LU Guarding LU Mass LU Other Comments PELVIS/GU/GI No abnormalities Not assessed Pelvis Tenderness Unstable Other GU/GI Incontinence Hematuria Rectal Bleed Other Comments LL LL LL LL RL RL RL RL SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 16 of 18 EXTREMITIES No abnormalities Not assessed Delayed Capillary Refill LA RA LL RL Abnormal Sensation LA RA LL RL Edema LA RA LL RL Atraumatic Pain LA RA LL RL Weakness LA RA LL RL Paralysis LA RA LL RL Other LA RA LL RL Comments NEUROLOGICAL No abnormalities Not assessed Neurological Weakness – Left sided Weakness – Right sided Abnormal Gait Facial Droop Tremors Slurred Speech Other SAVE your entries NARRATIVE PAGE CLINICAL IMPRESSION PRIMARY IMPRESSION a. Abdominal pain/problems s. No complaints or Injury/Illness noted b. Airway obstruction t. Obvious death c. Allergic reaction u. Other d. Altered Level of Consciousness v. Pain (nontraumatic) e. Behavioral/psychiatric disorder w. Poisoning/drug ingestion f. Cardiac arrest x. Pregnancy/ob delivery g. Cardiac rhythm disturbance y. Respiratory arrest h. Chest pain/ discomfort z. Respiratory distress i. Diabetic symptoms aa. Seizure j. Electrocution bb. Sexual assault / rape k. Epistaxis cc. Smoke inhalation l. Generalized weakness dd. Stings / venomous bite m. Hemorrhage ee. Stroke/CVA n. Hypertension ff. Syncope/fainting o. Hyperthermia gg. Traumatic Circulatory Arrest p. Hypothermia hh. Traumatic Injury q. Hypovolemic/ shock r. Inhalation injury (toxic gas) ii. Vaginal hemorrhage SECONDARY IMPRESSION Additional complaints that the patient may have This is the same drop down list as the primary impression SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 17 of 18 INJURY DETAILS PRIMARY a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. PLACE OF INJURY a. b. c. d. e. f. Bicycle accident Bite Chemical poisoning Child abuse Drowning Drug poisoning (accidental) Electrocution (lightening) Electrocution (non lightening) Excessive cold Excessive heat Fall Fire & Flame Firearm (accidental) Firearm (assault) Firearm (self inflicted) p. q. r. s. Machinery accident Mechanical suffocation Motor Vehicle Accident Non motorized vehicle accident t. Radiation exposure u. Railway incident v. Rape w. Self inflicted x. Smoke inhalation y. Stabbing/cutting (accidental) z. Stabbing/cutting (assault) aa. Struck by blunt / thrown object bb. Venomous sting Home Street / Highway Doctors office Nursing Home Assisted Living Center Hospital ER g. h. i. j. k. Hospital – other or unspecified location Dialysis EMS provider Other specified place Rehabilitation Center Once you select the Primary Injury the Details field and Place of Injury become mandatory fields Along with a date field. NARRATIVE BOX Fill in your narrative about the incident in this area SAVE your data APPENDED NARRATIVE BOX This area is the addendum section of the report If you need to make changes to the Incident Detail, Patient Information or Billing page of the report the changes will be made on these pages and then you must document “why” the changes were made in the appended narrative box. If you need to make changes to the Flowchart, Assessment or Narrative pages you will have to go to the Appended Narrative boxes and document the changes along with why you are making the changes. This area date and time stamps the changes made to the document. Spell check is available on the bottom of the page. SAVE your entry SOUTHERN FOX VALLEY EMERGENCY MEDICAL SERVICES SYSTEM TITLE: SFV/EMS System Run report NUMBER: F 2.0 SECTION: Quality Assurance and Data Collection PREPARED BY: EMS Administration DATE REVIEWED: 06/18/14 DATE REVISED: 05/27/09 DATE INITIATED: 3/l/90 REVISION NO: 3 Page 18 of 18 BILLING PAGE - Data entry into this page of the report may occur by people other than the responders. This will be department specific PATIENT INSURANCE DATA HIPAA Notice yes no Billing Consent signature obtained signature not obtained unable to sign Transport Refusal signature obtained signature not obtained unable to sign (if applicable) PAYER INFORMATION - Insurance information getsentered into this location SAVE your data PATIENT NEXT OF KIN DATA: First Name Last Name Address Relationship to Patient – Spouse, Parent, Sibling, Child, other Check box to copy patient address to this area SAVE your data MEDICAL NECESSITY REASON FOR HOSPITAL TO HOSPITAL TRANSFER These areas are for the use of the billing people CONSUMABLES – this area will be department specific and optional in use. This will be a pre populated drop down list specific to the individual departments Typically this area is used as a running inventory for items not supplied by the hospitals. SPECIALTY PATIENT PAGE – These pages go into to specific patient information regarding the following categories. Spinal Screening Page - This page documents the Spinal Assessment screening criteria for determining if Spinal Restriction is necessary MVC – It is highly recommended that this page be filled out for any MVC. This page will give the receiving facility valuable information regarding the accident. Trauma Services at each hospital also track this type of information for statewide database. This page could become mandatory in the future. CPR – It is highly recommended that this page be filled out any time CPR is performed. This page may become mandatory. The data on this page gives additional patient and intervention documentation for the arrest patient OB – It is recommended that this page should be filled out for any OB patient. The information on this page will give the receiving facility pertinent information in regards to this pregnancy. STROKE – It is highly recommended that this page be filled out for any suspected stroke patient. Currently this page uses the Los Angles Prehospital Stroke Screen but we will be changing it to the Cincinnati Stroke Screen. This may become a mandatory page in the near future.