Free F-47300 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7300 (Rev. 01/01)
Date Incident Reported

AMBULANCE RUN REPORT (Page 3) Skills / Extended Comments
Completion of this form meets the requirements of administrative rule HFS 110.04(3)(b). Client information in this document is confidential under Wis. Stat. 146.82(1).

STATE OF WISCONSIN Adm. Code HFS 110.04(3)(b)
Patient Care Record / Alarm No.

Patient Last Name / First / MI

Service Name and ID No. Cardiac Rhythm Interpretation Blocks

Responding Unit

Time

EMT

Blood Pressure

Rate

Pulse Quality

Rate

Resp Quality

SPO2

Procedure

No. of Attempts (Joules for Defib) Success

Medications

Dose

Route

A D V A N C E D S K I L L S

Airway complications o Nasal o None o Dental o Pharyngeal o Other _________ o N/A o Esophagus o Trachea Equipment Failure Differential Diagnosis Additional Comments

Airway Placement verified by EMT o Auscultation o Tube Check o Visualization o End Tidal CO2 o N/A

Airway Placement Prehospital Outcome ER Outcome o Admitted to Hospital Hospital Outcome verified by MD o Transferred o Transferred o Discharged Arrived at Hospital w/ Pulse o Discharged o Discharged AMA o Died o Unknown o Died oYes o No oN/A o Yes o No o Unknown o N/A

o Yes o No

Explain:

oN/A

ALS Provider Arrival:

o N/A

SIGNATURE -- Medical Control Physician SIGNATURE AND NUMBER -- EMT SIGNATURE AND NUMBER -- EMT