Download patient movement request af 3899

PATIENT MOVEMENT REQUEST AF 3899
DATA PROTECTED BY PRIVACY ACT OF 1974
KYANG 123d CCATT Team
C-130 1300
O/C Captain Kirk
PATIENT DEMOGRAPHICS
Patient Name:
ID:
Nationality: UNITED STATES
Status:
Grade:
Age:
Cite #:
Gender:
Will Return?: U
Precedence:
Classification:
Special: YES
CCATT: YES
ADMINISTRATIVE DATA
Originating MTF: FOB
Destination MTF:
Appt:
Attending Physician:
Ward Name:
Last PMR State Changed By:
Accepting Physician:
Max Stops:
CLINICAL DATA
Origination ICAO:
Destination ICAO:
Casualty Event:
DSN Phone:
DSN Phone:
DSN Phone:
DSN Phone:
Altitude Restriction: NO
Max RONs:
Primary Med Spec:
Secondary Med Spec:
Other Med Spec:
Ready Date:
Reason Regulated:
Source System: T-WEB
Com Phone:
Com Phone:
Com Phone:
Com Phone:
Comm Travel?:
Primary Diagnosis:
Secondary Diagnosis:
Other Diagnosis:
Patient
History:
MEDICATIONS
Medication Name
Special Diet:
Dose
Formula:
Infusion Rate:
VITAL SIGNS AND LABS
T:
HGB:
SPO2 Rate:
VENTILATOR
Freq
P:
HCT:
FiO2:
IV Location
IV Type
Amount:
R:
WBC:
Solution
Rate cc/hr
Allergies: Unknown
BP:
Date Taken:
Wt:
Oxygen Rate:
Oxygen Mode: VENT
Intubated with 7.5 ET, 24 cm at teeth
Settings: AC 14, TV 800, PEEP 5, FiO2 60%, Suction Amt: 2
PMI DATA
Cardiac monitor: yes
Ventilator: yes
Suction: yes
Pump: total of 3
Pulse Ox: yes
Stryker: no
TRANSPORTATION INFORMATION
Orig Transport Name:
Dest Transport Name:
POC:
POC:
ADMIN REMARKS
Blood type: AB POS
ICP Monitor: no
Com Phone:
Com Phone:
DSN Phone:
DSN Phone:
REQUIRES CCATT 1:1, CCATT MUST BRING ALL MEDS NEEDED FOR TEAM TRANSPORT
ATTENDANTS
Attendant Name
Status
Grade
Age
Gender
Type