Download F 02 SFVEMS Run Report - Southern Fox Valley EMS System

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.