Medical Incident Report (Page 2 of 2) in pdf

Medical Incident Report Page 2

MEDICAL INCIDENT REPORT

5. Treatment

Check all Boxes that apply:

Accucheck

Glucose tab

Juice

Water

Antiseptic cleaning

Band aid /gauze

Ice pack

Aspirin (qty: _____)

Neuro (PERRLA)

Splint location: ______________________________

CPR

AED

Vital signs - Please fill out below

VS – Time

Heart Rate

Respiratory Rate

Blood Pressure

Treatment administered

BY:

SIGNATURE: _____________________________________________

Description:

_______

Patient refused medical attention:

YES

Patient advised to go to hospital & refused

YES

911 called at what time: ___________________

Paramedic response: please note arrival time: _______________________________________

Police/Fire Dept Response: please note Officer’s Name & Badge #:

_________Report Number:________________

A appropriate, please have this hardcopy reviewed by a Ministry leader for potential patient

follow-up.

Patient called: Date & Time_____________________by:_______________________________

Comments:

2015 Harvest Bible Chapel | Business Operations

Page 2 of 2

Medical Incident Report Page 2