Hics 254 Form -Disaster Victim Patient Tracking

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HICS 254 – DISASTER VICTIM / PATIENT TRACKING
1. Incident Nam e
2. Operational Period (#
)
TO: ____________________________________________
DATE:
FROM: _____________________________________
TO: ____________________________________________
TIME:
FROM: _____________________________________
3. Area (Triage or Speci f ic Treatment Area)
DISPOSITION / TIME
TRIAGE CATEGORY
DOB / AGE
(D) DISCHARGE
NAME
IMMEDIATE
SEX
(A) ADMIT
FIELD TAG
MEDICAL RECORD
(LAST NAME, FIRST NAME)
DELAYED
LOCATION / TIME OF PROCEDURES
(M/F)
NUMBER
NUMBER
(S) SURGERY
MINOR
(CT, X-RAY, ETC.)
EXPECTANT
(T) TRANSFER
EXPIRED
(M) MORGUE
4. Prepared by
PRINT NAME: _____________________________________________________________________
SIGNATURE: _______________________________________________________________________
DATE/TIME: ______________________________________________________________________
FACILITY: __________________________________________________________________________
Purpose:
Records the triage, treatment, and location of victims/patients
HICS 254 | Page 1 of 1
Origination:
Patient Tracking Manager or team
Copies to:
Situation Unit Leader, Patient Registration Unit Leader, Planning Section Patient Tracking Manager, Medical Care Branch Director, and Documentation Unit Leader
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