Preliminary Report
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1Preliminary
Date
Agency Name
Agency Number
Type of Service Requested
Report*
911 Resp. (Scene)
Interfacility Trans.
Transport Unit #
Call Sign #
EMT B / I / P
EMT B / I / P
PCR #
Revision 2
Medical Trans.
Standby
Intercept
Mutual Aid
Age
Date of Birth
Sex
Phone Number
Work Related/Occup.
Patient Name
M F
Patient Address
City
State
Zipcode
Race/Eth.
Social Security Number
Legal Guardian if Patient is a Minor
Relation to Patient
Insurance Company
Location / Address of Call or Incident
Other Agencies
Same as Above
Response Mode to Scene
Dispatch Complaint
EMD Performed
Lights and Sirens
No Lights and Sirens
Downgraded to No L&S
Upgraded to L&S
EMD Card #
Prior to Arrival
PSAP Call Date/Time
AED
Arrest Witnessed By
Downtime
Performed By:
Mechanism or Cause?
Yes No
On Scene Prior
EMS/1st R
EMS/1st R/PD
< 5 minutes
to EMS
PD
Family
5-10 minutes
Time Started
Unit Notified by Dispatch Date/Time
Bystander
Family
10-15 minutes
Yes No
Steering Wheel Deformity
Unknown
Bystander
Unknown
Windshield Spider
Chief Complaint
Unit En Route Date/Time
Dash Deformity
Lap Seat Belt
Side Post Deformity
Shoulder Belt
Unit Arrived on Scene Date/Time
Duration
Severity (1-10)
Min
Hrs
Days
Ejection
Helmet
Infant Carseat
Other Complaints
DOA Same Vehicle
Arrived at Patient Date/Time
Airbag
Rollover
Space Intrusion > 1 ft.
Unit Left Scene Date/Time
Duration
Severity (1-10)
Min
Hrs
Days
Fire
Time
BP
Temp.
HR
RR
Glucose
CO2
SaO2
Patient Arrived at Destination Date/Time
Extraction Time (min)
Unit Back in Service Date/Time
Fall (ft)
Unit Back at Home Location Date/Time
(Circle Pt. and
Beginning Odometer
Vehicle Impact Area)
Car
Sport Utility
On-Scene Odometer
Stationwagon
Truck
Van
Destination Odometer
Yes
No
Motorcycle
Evidence of Alcohol Ingestion?
DNR/MOST Form
Living Will
Bicycle
Loaded Mileage
Allergies
Boat
Denies
Narrative
Chest
Skin
HEENT / Neck
Heart
Abdomen
Pelvis / Gen.
Extremities
Back
Abnormalities
Normal
Normal
Normal BS
Normal
Normal Tenderness
Normal
Tender Sp. Process
Pale
Normal
Decreased BS
Normal
Decreased Sounds
Distention
No
C T L
Cyanotic
JVD
Tenderness
Tender
Murmur
RUE
Tenderness
Tender Paraspinous
Clammy
Tracheal Dev.
Acc. Muscles
Unstable
Monitor/ECG/FHT’S
Guarding
No
C T L
Jaundiced
SQ Air
LUE
Flail Segment
Genital Injury
Mass
Pain to ROM
Cold
Stridor
Rhonchi / Wheezing
Crowning
1
RLE
Lac./Lesions
No
C T L
Warm
Lac. / Lesion
Rales
Lac./Lesions
R L UQ LQ
2
LLE
Diaphoretic
Lac./Lesions
Lac. / Lesion
Pupils
Findings
Deficit
Stroke Screen
L:
Dysphasia
React.
Dil __ mm
Nonreact.
Blind
Normal
Confused
Unresponsive
Seizures
Obtunded
Positive
Hemiplegia:
R
L
Combative
Hallucinations
R:
React.
Dil __ mm
Nonreact.
Blind
Post-ictal
Tremors
Negative
Spontaneous
4
Oriented
5
Obeys Commands
6
Total
10 - 29
= 4
> 89
= 4
13 - 15
= 4
Total
To Voice
Confused
4
Localizes to Pain
Reperfusion
3
5
GCS
Adult Trauma
> 29
= 3
76 - 89
= 3
9 - 12
= 3
To Pain
2
Inappropriate Sounds
3
Withdraws (Pain)
4
Check Sheet
Score
6 - 9
= 2
50 - 75
= 2
= 2
Score
6 - 8
None
1
Incomprehensible Sounds
2
Flexion (Pain)
3
No Contraindicators
1 - 5
= 1
1 - 49
= 1
4 - 5
= 1
None
1
Extension (Pain)
2
Contraindicators
None
= 0
None
= 0
3
= 0
None
1
Size
Tech State ID
Time
Medication
Time
Procedure
Success
Dose/Route
Tech State ID
Y N
Y N
Y N
Y N
Y N
Time
Cardiac Rhythm or 12 Lead Interpretation
ETT Confirmation and Signature at Destination
Transport Mode from Scene
Lights and Sirens
No Lights and Sirens
Downgraded to No L&S
Upgraded to L&S
Patient’s Condition
Reason for Choosing Destination (circle)
Treatment Authorized by
MD MICN
Safety
Moved to Ambulance Transport Position
Transport
on Arrival
Diversion
Closest Facility
Walk
Prone
Supine
Gloves
Refused
Insurance Status
Family Choice
Improved
Mask
Stretcher
L. Lateral
Sitting
Cancelled
On-Line Medical Direction
Law Enforcement Choice
Same
Patient Received by
Carry
Gown
Trendelenberg
Head Elevated
Patient Choice
Patient’s Physician Choice
Worse
Stairchair
Fowlers
Eyewear
Protocol
Specialty Resource Center
EMT Signature
Destination Name and/or Address
EMT-P
State ID
Medical Control Signature
* This is a preliminary document. This is not the final EMS Patient Care Report.
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