Free Ambulance Report, DPH 7119 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES
Division of Public Health DPH 7119 (Rev. 02/01)
Mo/Day/Yr

Completion of this form meets the requirements of administrative rule HFS 110.04(3)(b). Some client information in this document is confidential under Wis. Stat. 146.82(1). Service Name and ID No. Responding Unit Station

AMBULANCE REPORT

STATE OF WISCONSIN
Patient Care Record / Alarm No.

Adm. Code HFS 110.04(3)(b)

Date Incident Reported

Incident Address / Location

Incident Municipality

Incident County

Destination Address / Facility Name

Destination Municipality

Destination County

R E S P O N S E

Mileage:(Loaded) End Begin
(Use Military Times)

Total

Lights And Siren To Scene: o Non-Emergent, No Lights or Siren o Emergent, Lights and Siren
En Route At Scene

oN/A o Initial Emergent, Downgrade To No Lights and Siren o Initial Non-emergent, Upgrade To Lights and Siren
At Pt. Lv. Scene

Crash Report No.

Call Rec. Pt. Det. Crew Member Name / License No. 1.

At Dest.

In Service

Location Type

o Airport

Response Type

o Clinic / Medical o Educational Inst. o Farm o Mutual Aid o Intercept

2.

o Highway / Street o Industrial o Home / Residence o Mine / Quarry o Hospital o Nursing Home o Response To Scene o Scheduled Interfacility Transfer
City

3.

o Public Building o Residential Inst. o Unspecified o Public Outdoors o Restaurant / Bar o Other ________ o Recreational / Sport o Waterway o Standby o Unknown o Unscheduled Interfacility Transfer
State Zip Code Phone ( )

4.

oN/A oN/A

Patient Last Name / First / M.I.

Mailing Address

Emergency Contact Name

Address

City

State

Zip Code

Phone (

)

D E M O Social Security No. (Optional) G R A Employer P H I Insurance 1 C S
Insurance 2 If MVA, Agency

Personal Physician

oN/A
Race
Address

Date of Birth

Age

Weight

o White o Hispanic o Asian/Pacific Islander

City

o Black o American Indian/Alaska Native o Other

o Unknown
Zip Code

o lbs o Male o kg o Female
Work Related Injury o Yes o No
Phone ( )

Gender

State

Group No.

Insured No.

Address

Phone

Group No.

Insured No.

Medicare

HMO

Medicaid

Signs / Symptoms o Abdominal Pain o Back Pain o Bleeding

H o None o None Patient's Current Medications I Allergies S Dose T O R Y Dose Pre-Existing Medical Condition -- Medical o CVA / TIA o Asthma o Hypotension o Diabetes o Seizures / Convulsions o Bleeding Disorders o Gastrointestinal o Tuberculosis o Cancer ________ o Chronic Renal Failure o Headaches o Chronic Resp. Failure o Hepatitis Vitals o Vital Continued with Advanced Skills Time BP Pulse Rate Qual. Resp. / SPO2
1 2 3 4 5

o Bloody Stool o Breathing Difficulty o Cardiac Arrest o Chest Pain o Choking

o Diarrhea o Dizziness o Ear Pain o Eye Pain o Fever/Hyperthermia

o Headache o Hypertension o Hypothermia o Nausea o Numbness

o Paralysis o Palpitations o Pregnancy / Childbirth o Respiratory Arrest o Seizures / Convulsions

o Syncope o Weakness o Trauma o Unknown o Unresp. / Unconscious o Other ___________ o Vaginal Bleeding o None o Vomiting Last Oral Intake

Dose

Dose

Dose Dose oN/A Cardiac Other o Angina o Myocardial Infarction o Developmental Delay / MR o Other _______ o Cardiac Surgery o Psychiatric o None o Arrhythmia o Congenital o Substance Abuse o Tracheostomy o Congestive Heart Failure o Hypertension Eyes Breath Sounds oN/A Mental Status/Behavior

Level of Resp. Effort Consciousness
Normal Labored Shallow Absent Assisted A - Alert______ V - Verbal P - Pain U - Unresp

A S S E S S M E N T

o Reg o Irr o Reg o Irr o Reg o Irr o Reg o Irr o Reg o Irr

o PERRL o Normal R Reactive o Acute Confusion R Nonreactive o Usually Confused R Constricted o Incoherent o Intermittent Consciousness R Dilated R Blind o Combative
R R Cataracts Glaucoma

L L L L L L L

R R R R R

Clear Wet Decreased Wheeze Absent Stridor

L L L L L

o

C CPR Provider: o Bystander o First Responder Unit o EMS Unit o Unkn P R CPR Start Time _______ Discontinue ____________ Witnessed Arrest

o Yes o No

Defib Provider: o PAD o First Responder Unit: ________ o EMS Unit: ________ Time _________

Pain Provoke: ________________________ Skin Moisture Color Quality Radiate Severity Time (Onset) o Normal o Normal Temp o Normal o Dry o Cyanotic Sharp No (1-10) 0-15Min o Cool/Cold o Moist o Pale-Ashen Dull Yes _____ 15-60 Min o Warm/Hot o Diaph o Cherry Cramp _____ 1-12 Hr o Flushed Crushing 12-24 Hr Capillary Refill o Jaundice Constant Other: ____ o Normal o Delayed oN/A oN/A

oN/A

oN/A

oN/A

oN/A

DEPARTMENT OF HEALTH & FAMILY SERVICES
Division of Public Health DPH 7119 (Rev. 02/01) Service Name and ID No.

Completion of this form meets the requirements of administrative rule HFS 110.04(3)(b). Some client information in this document is confidential under Wis. Stat. 146.82(1). Patient Last Name / First / M.I.

AMBULANCE REPORT

STATE OF WISCONSIN

page 2

Patient Care Record / Alarm No.

Physical Examination P H Y S Injury / Pain Location I C Head / Face A L Neck E X A M I N A T I O N Chest / Axilla Abdomen Back / Flank Pelvis / Hip L Arm R Arm L Leg R Leg U U U U L L L L J J J J

ion ing __ as ell __ br tab Sw A S __ r / e / T __ t o ion ure issu __ FX sho (N t at __ nt is / er unc t T urn n in f u c __ D Pa Bl B Gu So La P m au a)

oN/A

Glasgow Coma Scale A. Eye Opening Scene Enroute Spontaneous 4 4 To voice 3 3 To pain 2 2 None 1 1 B. Verbal Response Oriented 5 5 Confused 4 4 Inappropriate words 3 3 Incomprehensible Words 2 2 None 1 1 C. Motor Response Obeys commands 6 6 Purposeful movement 5 5 Withdraws to pain 4 4 Flexion to pain 3 3 Extension to pain 2 2 None 1 1 A. + B. + C. = _____ Rprt ____

Time

T Motor Vehicle Crash R A U M A T I C P = Patient Location in Vehicle
Rear

oN/A

Type

I Cause of Injury N J o Aircraft Related U o Athletic Event R o Bicycle Crash Y o Bite

X = Location of Damage to Vehicle

o Car o Motorcycle o None o Truck o ATV o Minor o Van o Snowmobile o Moderate o Semi o Watercraft o Major o Bus o Aircraft o Rollover

oN/A

Exterior DamageoN/A Interior Damage

o None o Spidered Window o St. Wh. Bent o Compart. Intrusion o Patient Ejected

oN/A

Restraints Airbag Lap Belt Shoulder Belt Child Seat

Obs

oN/A o o o o

Safety Equipment

oN/A oN/A

o o o o

o Float. Dev. o None o Unknown o Helmet o Eye Prot. o Prot. Clothing o Stings (Plant / Animal) o Water Transport Incident o Unknown o Other ___________ o Syncope / Fainting o Traumatic Injury o Vaginal Hemorrhage o Unknown o Other ___________
EMT _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ EMT _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

oN/A o Chemical Exposure o Child Battering Suspected o Drowning o Drug Ingestion o Electrocution (Non-Light.) o Excessive Cold

o Excessive Heat o Fall o Fire / Flames o Firearm Self-Inflicted o Firearm Accidental o Firearm Assault

Provider Impression If more than one impression is checked, Circle Primary One o Electrocution o Abd. Pn. / Problems o Cardiac Arrest o Airway Obstruction o Cardiac Rhythm. Disturb. o GI Bleed o Allergic Reaction o Chest Pn. Discomfort o Headache o Altered L.O.C. o Congestive Heart Failure o Hypertension o Behavioral / Psych o Diabetic Symptoms o Hyperthermia / Fever Chief Complaint / Mechanism of Injury: Comments:

o Lightning o Machinery Injury o Mechanical Suffocation o Motor Vehicle (Non-Traff.) o Motor Vehicle (Traffic) o Pedestrian Traffic o Hypothermia o Hypovolemia / Shock o Intoxication Suspected / o Obvious Death o Poison / Drug Ingestion o Pregnancy / Ob Delivery
Time of Onset: Alcohol Ingestion

o Physical Assault o Poison, Not Drugs o Radiation Exposure o Sexual Assault o Smoke Inhalation o Stabbing o Respiratory Arrest o Respiratory Distress o Seizure o Sexual Assault / Rape o Toxic Inhalation o Stings / Bites o Stroke / CVA / TIA

C O M M E N T

Procedure or Treatment o Assisted Ventilation o Backboard o Bleeding Control o Burn Care o CPR o Cervical Immobilization o DNR Protocol o Glucose Administration o Nasopharyngeal Airway o Obstetric Care / Delivery o Oropharyngeal Airway o O2 By Mask ______ liters o O2 By Cannula ______ liters o Physical Exam o Radio / Phone Report o Splint of Extremity o Traction Splint o Vital Signs o OTHER: ________________ o None

If an advanced skill is performed, complete form DPH 7300 Incident Disposition o Treated / Transported by EMS Destination Type - AND - Destination Determination

o Dead at Scene M I Other Services on Scene Patient Transported o Cancelled S o Prone o Law Enforcement ______ C o Treated / No Transport o Unknown o Supine o Fire _______ E o Treat. / Trans. by Priv. Veh. o Sitting o Other ___________ L o Treat. / Trans. by Other Means o No Patient Found o Patient Restrained L o None o Treated and Released A o Physician o Head Elevated o Patient Refused Care N o First Responder _______ o Feet Elevated E o In _____ Lateral Position o Nurse / Physician Assistant O o Other ___________ oN/A U Time Report Received: By: S Arrival Status oN/A PPE Used oN/A Facility Notified By oN/A Difficulties Encountered o Dispatch o Other _____ Report Given To: ______________________________________ o Unchanged o Gloves o Radio oN/A o Extrication o Better o Gown o Phone EMT Signature o Hazardous Material o Worse o Goggles o Unable* o Language Barrier o DOA o Mask o No Need* o Road o Other ________ o Direct o Unknown o Unsafe Scene o EKG Telemetry * Explain________________ o Vehicle Problems oN/A o Weather

o Home / Residence o Police / Jail o Medical Office / Clinic o Skilled Nursing Facil. o Hospital Direct Admit o Hospital ED o Morgue o Other

o Closest Facility o Diversion o EMT Choice o Law Enforce. Choice o Managed Care o On Line Med. Direction o Patient / Family Choice o Patient / Phys. Choice o Protocol o Specialty Center o Other

o Treated / Transferred Care o To Aero-Medical Unit o To ALS Unit o To BLS Unit o To Law Enforcement

o No Treat. Needed

oN/A Lights And Siren During Transport: o Non-Emergent, No Lights or Siren o Emergent, Lights and Siren o Initial Emergent, Downgrade To No Lights and Siren o Initial Non-emergent, Upgrade To Lights and Siren