Pre-Hospital Care Report

Report Numbers

1. Patient Care Report #

2. EMS Response #

Incident & Unit

3. Incident Date

4. EMS Agcy #

5. Call Sign

6. Vehicle #

7. Station #

Dispatch & Unit Role

8. Complaint Reported By Dispatch

9. Emergency Medical Dispatch Performed

No Yes, With Pre-Arrival Instructions Yes, Without Pre-Arrival Instructions Yes, Unknown if Pre-Arrival Instructions Given

10. Primary Role of the Unit

Air Trans.-Helicopter Air Trans.-Fixed Wing Ground Trans. Non-Trans.-Rescue Non-Trans.-Assist

11. Level of Care of This Unit

12. Type of Service Requested

911 Response (Scene) 911 Response (Inter-Facility Transport) Inter-Facility Transport (Routine) Intercept Mutual Aid Public Assistance/Other Not Listed Medical Transport Standby

13. Response Mode to Scene / 14. From Scene

To Scene

Emergent Non-Emergent Emergent Downgraded to Non-Emergent Non-Emergent Upgraded to Emergent

From Scene

Emergent Non-Emergent Emergent Downgraded to Non-Emergent Non-Emergent Upgraded to Emergent

15. Type of Delay(s) — Dispatch

None/No Delay Caller (Uncooperative) High Call Volume Language Barrier Location (Inability to obtain) No EMS Unit(s) Available Safety Conditions Technical Failure Other (Not Listed)

16. Type of Delay(s) — Response

17. EMS Transport Mode

Run Times (Use Military Time)

18. PSAP Call

22. Unit Arrived at Scene

19. EMS Dispatch Notified

23. Arrived at Patient

20. Unit Notified by Dispatch

24. Transfer of EMS Patient Care

21. Unit En-route

25. Unit Left Scene

26. Patient Arrived at Destination

27. Transfer of Care to Destination

Unit Back In Service

28. Incident/Patient Disposition

29. Intercept Recipient Agency

Scene

30. # of Patients at Scene

Single Multiple None

31. Mass Casualty

Yes No NA

32. Incident Location Type

33. Latitude

33. Longitude

Odometer Readings & FAC ID

Begin

Arrive

Destination

End

34. Incident FAC ID

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