Medical Incident Report Template
ADVERTISEMENT
1Medical Incident Report
Date: _____________ Time: _______________Division: ________________
Line
Information
Notes
1.
2.
Level of Severity:
Triage Page 100, IRPG – 2014
ALS Ambulance or Air Medivac/Extraction.
RED/PRIORITY 1 – Airway obstruction; difficulty breathing; altered
Medical radio traffic has priority
Level Of Consciousness; major trauma/blood loss; cardiac chest
Emergency radio traffic restricted to:
0
0
pain; crush injury; penetrating wounds; open fracture; 2
or 3
burn >
On site Medic, Div. Sup. or on scene P.O.C.
5 palm sizes or suspected inhalation; severe allergic reaction.
Consider alternate freq.for esential OPS traffic.
Ambulance or air transport/extraction if at remote
YELLOW/PRIORITY 2 – Closed fracture; significant trauma/
location. Consider field medic transport.
0
0
lacerations; not able to walk; 2
or 3
burn < 5 palms sizes; allergic
Medical radio traffic may have priority as
reaction; significant sickness.
above.
MEDICAL TRANSPORT via crew, ground
GREEN/PRIORITY 3 – Small area abrasions or lacerations;
support, field medic, or air if at remote location.
allergic reaction; minor sprain; general sickness.
Fire radio traffic unchanged.
3.
Assessment Page 100, IRPG – 2014
On-Scene Point of Contact:_____________________________
Treatment Page 101-110
Patient Assessment / Injuries & Treatment:
4.
Level Of Consciousness_____________
Breathing_________________________
Age______Sex______Weight______
Pulse Rate________________________
Chief Complaint:_________________________________________
Skin Color - Normal Pale Bluish Red
_________________________________________________
Skin Moisture- Normal Dry Moist Profuse
______________________________________________________
Skin Temp.______Normal Hot Cool Cold
Treatment Plan:_________________________________________
Pupils___________________________
_________________________________________________
Blood Pressure______/_______
_________________________________________________
SpO
____________________________
_________________________________________________
2
Blood Sugar_______________________
______________________________________________________
Patient Location:
_________________________________________________
Drop Point, Staging area, Division, Spike,
Camp, Line area or GPS
O
O
Lat: _____
_____. _____’ Long: _____
_____. _____’
5.
On Scene Medical and IC:
Crew medic, Field medic
Who is the IC for this incident?
6.
Preferred PatientTransport Method:
MEDICAL TRANSPORT OPTIONS – Ambulance,
LZ Location / GPS
Air Medivac/Extraction, crew, ground support,field
LZ Hazards: Trees, power lines, Wind
medic,
O
O
direction, slope . Consider a Primary and
Lat: _____
_____. _____’ Long: _____
_____. _____’
Secondary response for all Red & Yellow
patients.
Ground Contact:
7.
Additional Resources
Hoist, SKED, Backboard, Litter, Rope,
Paramedic w/ALS,Trauma Bag, O2, AED,
Extrication, HAZ Mat,Fire Suppresion
8.
Documentation
9.
On Scene Changes:
Revised – 7/2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business