Emergency Medical Treatment Report
ADVERTISEMENT
1
2
3
4EMERGENCY MEDICAL TREATMENT REPORT
1. Name
10. Name:
11. Level:
RESCUER
12. Unit:
VICTIM
INFOR-
2. Sex (check one)
male
13. OPFAC #:
MATION
IDENTI-
female
14. Rescue Vehicle:
FICATION
15. Receiving Unit:
3. Estimated age
yrs
mos
16. Time Patient Transferred:
4. Date:
5. Type of incident:
NATURE OF EMERGENCY / MECHANISM OF INJURY
6. Time on scene:
a) marine
7. Time of incident:
b) aviation
DESCRIP-
c) industrial
TION OF
INCIDENT
8. Location:
d) auto
e) domestic
f) other
TREATMENT
OBSERVA-
(circle as needed)
TION OF
MEDICATIONS:
1 - dressing
VICTIM
2 - tx splint
ALLERGIES:
3 - splint
4 - c/collar
MEDICAL HISTORY / COMMENTS / ETC.
5 - back board
(include additional vitals, oxygen, fluids, etc.)
6 - tourniquet
7 - CPR
BACK
FRONT
8 - airway
9 - oxygen
H - hemmorage
F - fracture
10 - MAST
L - laceration
B - burns
11 - Miller B/B
S - soft tissue injury
O2 Liters
(Circle appropriate number or numbers)
1 - normal
4 - cyanotic
7 - cold
SKIN
2 - pale/ashen
5 - dry
8 - warm
3 - flushed
6 - moist
9 - hot
VITAL
TIME
SIGNS
OBSERVED
Alert
Responds to Verbal
LEVEL OF
CONSCIOUS
Responds to Pain
Uncon / Unresponsive
Perl
PUPILS
Unequal
Nonreactive
Dilated
Pinpoint
Rate (Numeric)
PULSE
Strong
Weak
Rate (Numeric)
BREATHING
Regular
Shallow
Labored
BLOOD
Blood Pressure
PRESSURE
TEMP
TIME
MEDICATIONS ADMINISTERED
DOSAGE
Temperature
ORAL
(circle)
RECTAL
MAST
MAST BP
COMPARTMENT
L
ABD
R
PRIORITY I
PRIORITY II
PRIORITY III
TRIAGE INFORMATION
(CIRCLE ONE)
U.S. DEP T. OF HOMELAND SECURITY, U S C G, CG- 5214 ( R ev. 6-04)
PATIENT COPY
Previous Edition May be Used
Reset
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business