Report Patient Care Chart PDF Template

The Report Patient Care Chart form is a crucial document used in prehospital care to collect essential data about patients involved in emergency situations. This form includes comprehensive information such as incident details, patient demographics, care protocols, and treatment outcomes, ensuring that healthcare providers maintain effective communication and continuity of care. Properly filling out this form is vital for both patient welfare and legal compliance, so be sure to click the button below to access it.

Overview

The Report Patient Care Chart is an essential document utilized in emergency medical services (EMS) to accurately record patient encounters during prehospital care. This comprehensive form captures critical data, including incident specifics like the date, location, and nature of the emergency, as well as pertinent details about the patients involved. It allows EMS personnel to document various aspects of the patient's condition, treatment administered, and the response encountered by the team. Key sections of the chart cover the patient’s demographics, current medications, allergies, and the chief complaint, ensuring that providers have relevant information at their fingertips. Additionally, the form addresses the incident’s disposition, noting whether patients were treated and transported, refused care, or if other outcomes occurred. Vital signs, procedures conducted, and any barriers encountered before or during care are also meticulously recorded. This collective information not only aids in immediate care but also facilitates continuity of care during hospital transfers and provides crucial data for quality assurance and improvement initiatives.

Report Patient Care Chart Preview

GENERIC RUN REPORT

Prehospital Patient Care Chart

INCIDENT NUMBER

UNIT ID

INCIDENT DATE

INCIDENT ADDRESS

INCIDENT CITY

INCIDENT STATE

INCIDENT ZIP CODE

INCIDENT COUNTY

INCIDENT LOCATION TYPE SEE REF. SHEET

COMPLAINT REPORTED BY DISPATCH SEE REF. SHEET

PRIMARY PAYMENT

EMERGENCY MEDICAL DISPATCH PERFORMED

LEVEL OF SERVICE

SEE REF. SHEET

Yes w/pre-arrival instructions

BLS, Emergency

Yes w/out pre-arrival instructions

ALS, Level 1 Emergency

INCIDENT/PATIENT DISPOSITION

ALS, Level 2

Treated, Transport EMS

No Patient Found

Treated, Transferred care

Treated, Transported Law Enforcement

Specialty Care Transport

Cancelled

No Treatment Required

Pt Refused Care

Helicopter

Treated

& Released

Dead at Scene

Treated, Transported Private Vehicle

Not Applicable

NUMBER OF PATIENTS ON SCENE

MASS CASUALTY

TYPE OF SERVICE REQUESTED

PRIMARY ROLE OF THE UNIT

Single

None

Yes

Scene Response

ED to ED Transfer

Transport

Non-transport

Multiple

Mutual Aid

Intercept

Supervisor

Rescue

TYPE OF DELAY (S)

DISPATCHER

RESPONSE

SCENE

TRANSPORT

RETURN

None-N/A

Not known

Crowd

Clean up

Caller Uncooperative

Directions

Decontamination

High Call Volume

Distance

Documentation

Language Barrier

Diversion

ED Overcrowding

Location (Inability to obtain)

Hazmat

Extrication>20 Min

Hazmat

Equipment Failure

No Unit Available

Safety Conditions

Hazmat

Safety Conditions

Equipment Replenishment

Safety Conditions

Staff Delay

Language Barrier

Staff Delay

Other

Technical Failure

Traffic

Safety Conditions

Traffic

Staff Delay

Other

Ambulance Crash

Staff Delay

Ambulance Crash

Ambulance Failure

Traffic

Ambulance Failure

Weather

Ambulance Crash

Weather

Other

Ambulance Failure

Other

Weather

Other

PATIENT LAST NAME

PATIENT FIRST NAME

PATIENT ADDRESS

SAME AS INCIDENT

PATIENT CITY

PATIENT STATE

PATIENT ZIP CODE

AGE

DATE OF BIRTH

GENDER

RACE

ETHNICITY

Female

Male

CURRENT MEDICATIONS

ALLERGIES

PERTINENT HISTORY

INJURY PRESENT

CAUSE OF INJURY SEE REF. SHEET

TYPE OF INJURY

ALCOHOL/DRUG USE INDICATORS

Yes

Blunt

Penetrating

None

Pt admits to drug use

Burn

Not Known

Smell of alcohol on breath

Pt admits to alcohol use

Alcohol and/or drug paraphernalia at scene

CHIEF COMPLAINT

CONDITION CODE SEE REF. SHEET

CHIEF COMPLAINT ANATOMIC LOCATION

CHIEF COMPLAINT ORGAN SYSTEM

Abdomen

Extremity Lower

General/Global

CNS/Neuro

OB/GYN

Pulmonary

Endocrine/Metabolic

Chest

Back

Extremity Upper

Global

Renal

Cardiovascular

Gastrointestinal

Head

Neck

Genitalia

Psych

Skin

Musculoskeletal

CARDIAC ARREST

RESUSCITATION

CAUSE OF CARDIAC ARREST

Yes, Prior to Arrival

Defibrillation

None-DOA

Presumed Cardiac

Respiratory

Yes, After Arrival

Ventilation

None-DNR

Trauma

Electrocution

Chest Compressions

None-Signs of life

Drowning

Other

USE OF SAFETY EQUIPMENT

AIRBAG DEPLOYMENT

N/A

Lap Belt

Shoulder Belt

Protective Clothing

None Present

Deployed Front

Not Known

Helmet Worn

Protective Non-Clothing Gear

Other

Not Deployed

Deployed Side

Child Restraint

Eye Protection

Personal Floatation Device

None

Deployed Other

N/A

BARRIERS TO STANDARD PATIENT CARE

Development Impaired

Physically Impaired

Unattended/Unsupervised

Hearing Impaired

Physical Restraint

Unconscious

Language

Speech Impaired

RESPONSE MODE

TRANSPORT MODE

Initial Call for Help

Unit Left Scene

Lights/Sirens

Unit Notified

Patient arrived at Destination

No Lights/No Sirens

Unit En Route

Incident Completed

Initial Lights/Sirens Downgraded to no Lights/Sirens

Arrive on Scene

Available for Next Incident

Initial No Lights/Sirens Upgraded to Lights/Sirens

Arrived at PT.

PRIOR AID SEE REF. SHEET

PRIOR AID OUTCOME Improved

Unchanged

Worse

Unknown

PERFORMED BY

MEDICATIONS/ PROCEDURES

PERFORMED BY

MEDICATIONS/PROCEDURES

INCIDENT NUMBER

UNIT ID

INCIDENT DATE

TRAUMA TRIAGE CRITERIA

2nd/3rd burn >10% BSA or

Flail chest

ADULTS ONLY

face/feet/hand/genital/airway

Torso inj w/abd tender/ distended/seatbelt sign

Pulse >120 w/hemor shock

PEDS ONLY

Amp prox to wrist/ankle

LOC >5 min

Tension pneumothorax

Poor perfusion

Decreasing LOC

Mech of inj

Resp <10 or >29

Resp distress/failure

GCS Motor <4

Did not meet any triage criteria

Required intubation

GCS Total <13

Pen inj head/neck/torso

SysBP <90, or no radial pulse

Head/neck/torso crush

Pen inj prox to knee/elbow w/neurovasc comp

w/carotid pulse

Extremity inj w/neurovasc comp

Spinal cord inj

Extremity crush

Special Considerations

Torso inj w/pelvic fx

2+ prox humerus/femur fxs

SYMPTOMS

PRIMARY=P

ASSOCIATED=A

PROVIDER IMPRESSION

PRIMARY=P

SECONDARY=S

P A

P S

None

Mass/Lesion

Abd pain

Electrocution

Resp arrest

Bleeding

Mental/Psych

Airway obstruct

Hyperthermia

Resp distress

Breathing

Nausea/Vomiting

Allergic rxn

Hypothermia

Seizure

Changes in Responsiveness

Pain

Altered LOC

Hypovolemia/shock

Sexual assault/rape

Choking

Palpitations

Behavior/psych

Inhalation/toxic gas

Stings/bites

Death

Rash/Itching

Cardiac arrest

Inhalation/smoke

Stroke/CVA

Device/Equip Prob

Swelling

Cardiac arrhythmia

Death

Syncope

Diarrhea

Transport Only

Chest pain

Poisoning/drug OD

Injury

Drainage/Discharge

Weakness

Diabetic

OB/delivery

Vag bleed

Fever

Wound

Malaise

MEDICATIONS

TIME

MEDICATION

DOSE

ROUTE

REACTIONS SEE REF. SHEET

PROCEDURES

TIME

PROCEDURE

# ATTEMPTS

SUCCESSFUL

COMPLICATIONS SEE REF. SHEET

YES

VITAL SIGNS

SEE REF. SHEET

TIME

PULSE

SYS BP

DIA BP

RESP

O2 SAT

GCS EYE

GCS VERBAL

GCS MOTOR

ADV DIRECTIVE

DESTINATION

State DNR Form

Family Request DNR (no form)

Living Will

Other Healthcare DNR

None

Other

TYPE OF DESTINATION

REASON FOR CHOOSING DESTINATION

ED DISPOSITION

HOSPITAL DISPOSITION

Hosp ED/OR/L&D

Closest

On-line Med Control

Admit-floor

Death

Other EMS (air)

Admit-ICU

Discharge

Diversion

Other

Other EMS (ground)

Death

Transfer-other hosp

Family Choice

Pt. Choice

Other

Discharge

Transfer-nursing home

Insurance

Pt. Physician’s Choice

Transfer-other hosp

Transfer-other

Law Enforcement Choice

Protocol

Transfer-rehab

NARRATIVE

CREW MEMBER

↓ Report Patient Care Chart

File Properties

Fact Name	Description
Purpose of the Form	The Report Patient Care Chart is designed to document prehospital patient care, ensuring accurate records for treatment provided during emergencies.
Incident Information	This form captures essential incident details, such as the incident number, date, and location. These specifics help in organizing and referencing care provided during multiple incidents.
Patient Identification	It includes vital patient identification information, including the patient's name, address, age, date of birth, gender, race, and ethnicity, which aids in accurate record-keeping and potential follow-up.
Assessment of the Patient	Paramedics can record patient assessments, such as current medications, allergies, and pertinent medical history, to provide context for the care rendered.
Treatment and Action Taken	The form allows providers to detail treatments administered, procedures performed, and any medications given to the patient, ensuring comprehensive care documentation.
Incident Disposition	This section describes the outcome of the incident, including whether the patient was treated and transported, released, or declared dead at the scene.
Barriers to Care	Providers can note any barriers encountered during the response, such as communication issues or environmental factors, which may have impacted patient care.
Legal Compliance	In many states, the use of this form is governed by specific laws and regulations ensuring patient information is recorded accurately and protected under privacy laws.
Data Submission	The information collected on the form is often submitted to state or federal agencies for data analysis, helping improve emergency medical services across the board.
Use in Quality Assurance	This form serves an important role in quality assurance and improvement initiatives, allowing departments to review cases and enhance future patient care protocols.

Instructions on Utilizing Report Patient Care Chart

Filling out the Report Patient Care Chart form is essential for documenting the care provided to a patient during a prehospital emergency. Accurate and thorough completion of the form ensures that important information is conveyed for patient continuity and legal reasons. Here’s a straightforward guide to help you navigate through the process efficiently.

Locate the form. Ensure you have the correct Report Patient Care Chart form available, either in paper form or digitally.
Enter incident details. Fill in the following fields: Incident Number, Unit ID, Incident Date, Incident Address, City, State, Zip Code, County, and Location Type.
Record key complaint information. Note the Complaint, Referred by Dispatch, and indicate whether Emergency Medical Dispatch was performed.
Specify the level of service. Check the appropriate options for the Level of Service: BLS, ALS, or Emergency, and indicate the incident/patient disposition.
Indicate the number of patients. State the Number of Patients on Scene and whether it was a Mass Casualty Incident.
Outline type of service requested. Choose among options like Scene Response, ED to ED Transfer, and Transport.
Document response mode. Fill in Initial Call for Help, Unit Left Scene, Unit En Route, and any upgrades or downgrades in response mode.
Provide patient details. Enter the patient’s Last Name, First Name, MI, Address, City, State, Zip Code, and Age, along with the Date of Birth, Gender, Race, Ethnicity, Current Medications, and Allergies.
Detail the medical history. Include Pertinent History, Injury Present, Cause of Injury, and any indicators of Alcohol or Drug Use.
Describe chief complaints. Fill in the Chief Complaint Condition Code, Anatomic Location, and Organ System affected.
Record vital signs. Log the Time, Pulse, Blood Pressure (SYS and DIA), Respiratory rate, O2 saturation, and GCS (Eye, Verbal, Motor).
Review and finalize. Double-check all entries for accuracy and completeness, ensuring signatures are in place if required.

After all sections are properly filled out, the form is ready for submission or for further processing. It's crucial to maintain confidentiality while ensuring that all relevant information is communicated effectively for continued patient care.

Important Facts about Report Patient Care Chart

What is the purpose of the Report Patient Care Chart form?

The Report Patient Care Chart form serves as a comprehensive record of prehospital patient care provided by emergency medical services. It captures vital information about each incident, such as the patient's demographics, medical history, and treatment administered. This documentation is crucial for various reasons, including ensuring continuity of care, meeting legal obligations, and assisting with billing and insurance claims. By systematically organizing information about the patient's condition, the care given, and the disposition of the patient, the form creates a reliable communication tool among healthcare providers.

What information is required when filling out the form?

Several sections of the Report Patient Care Chart must be completed to provide a complete picture of the incident. Key details include the incident number, unit identification, date and location of the incident, and for each patient, their name, age, and relevant medical history. Patient assessment details, such as vital signs, chief complaints, and any medications administered, are also critical. There are sections addressing the patient's response to treatment, the transport mode, and the ultimate destination. This thorough data collection helps ensure that all aspects of patient care are documented accurately.

How does the form assist in the documentation of patient care and treatment?

The Report Patient Care Chart form plays an indispensable role in documenting the care provided during emergency situations. By encoding detailed information such as vital signs, treatments given, and the patient's response, it assists healthcare providers in maintaining a complete record of events. In cases where legal or medical queries arise, the form provides a structured narrative that reflects the care delivered. Additionally, having a standardized format ensures that all necessary information is captured consistently across different incidents and providers, facilitating better understanding and communication among medical teams.

What happens if some information is not available at the time of filling out the form?

If certain information is not available while completing the Report Patient Care Chart, it is essential to note that the data is missing or unknown rather than leaving sections blank. This may involve indicating unknown responses or using appropriate codes as specified in the form. Completing as much information as possible is crucial, as missing data might impact follow-up care or insurance claims. It is permissible to revisit and update the form later if details become available, ensuring that the record remains as complete and accurate as possible. Documentation accuracy directly influences patient safety and care continuity.

Common mistakes

When filling out the Report Patient Care Chart form, people often make several common mistakes. One of the biggest issues is leaving out essential details. For instance, if the **incident number** or **date** is missing, it can create confusion down the line. This information is crucial for tracking and reporting purposes.

Another frequent error occurs in the section regarding the **patient's medications** and **allergies**. Failing to list current medications or any known allergies can endanger the patient's safety. Accurate information in this area is vital for treatment decisions and ensuring the patient receives the appropriate care.

A third mistake involves not providing enough detail in the **chief complaint** section. Simply stating “chest pain” without including additional information, like the duration or severity, can lead to misunderstandings about the patient's condition. This section requires clear and concise details that guide subsequent care.

People often overlook the importance of the **narrative** at the end of the form. This section gives a comprehensive overview of the patient's condition and the actions taken by emergency personnel. If this is filled out poorly or left incomplete, it may lead to misinterpretation of the event and the care provided.

Lastly, a common mistake is not correctly identifying the **type of service requested**. If this is marked inaccurately, it can lead to delays in treatment. Whether it is labeled as a transport versus a mutual aid situation can significantly impact how the case is managed. Getting these details right is essential for proper protocol adherence.

Documents used along the form

The Report Patient Care Chart form is a crucial document in the realm of emergency medical services (EMS). However, several other forms and documents often accompany it to ensure a comprehensive record of patient care and procedures. The following list outlines eight key forms that help enhance communication, documentation, and ultimately, patient care.

Incident Report: This document captures all pertinent details about the emergency incident, including the sequence of events and actions taken by the EMS team. It provides a legal overview should any questions about the incident arise later.
Patient Assessment Form: This form is used to outline the initial findings during a patient evaluation, including vital signs, physical examinations, and patient history. It is essential for tracking the patient’s condition over time.
Treatment Authorization Form: This document is necessary for obtaining permission from the patient or their guardian to administer certain treatments. It ensures that the patient is informed and consents to specific medical interventions.
Transport Log: A record that details the transportation of patients, including the time of transport, destination, and modes of transport. This log is vital for ensuring accountability and can assist in data tracking for service improvement.
Patient Discharge Instructions: After receiving treatment, patients are provided this document, which contains important guidelines regarding follow-up care, medication instructions, and signs to watch for after leaving EMS care.
Medication Administration Record (MAR): This form documents all medications given to the patient during the EMS encounter, including dosages and administration routes. Accuracy in this record is crucial to avoid medication errors.
Billing Form: This form captures billing information related to services rendered, ensuring that the correct charges are processed with the insurance provider or patient. It plays a key role in the financial aspect of healthcare delivery.
Quality Assurance Review Form: Used to evaluate and review the care provided during the incident, this form helps in assessing performance, compliance with protocols, and identifying areas for training or improvement.

Collectively, these forms contribute to a robust system for managing patient information and service delivery in emergency medical services. Having them organized and easily accessible is essential for maintaining high standards of patient care and operational efficiency.

Similar forms

Patient Transfer Documentation: Much like the Report Patient Care Chart, this document captures information regarding patient transfers between facilities. It details the patient's condition at the time of transfer, the treatments administered, and the reasons for the transfer, emphasizing continuity of care.
Emergency Medical Services Report: Similar to the Report Patient Care Chart, this report outlines the actions taken by EMS during a response. It includes incident details, patient information, and medical interventions provided, ensuring comprehensive documentation of emergency care.
Trauma Assessment Form: This form addresses critical patient information, focusing predominantly on injuries, mechanisms of injury, and initial assessments. Like the Report Patient Care Chart, it serves to evaluate and record patient conditions promptly during emergencies.
Patient Medical History Form: This document collects detailed background on a patient's health, medications, and allergies. It complements the Report Patient Care Chart by providing essential baseline information necessary for informed decision-making during emergency care.
Incident Report: This type of document outlines the specifics of an incident, including the actions taken and any potential complications. It shares similarities with the Report Patient Care Chart in its focus on the events that occurred, allowing for thorough review and analysis.
Patient Care Plan: This plan outlines the approach to treating a patient based on their unique needs. Like the Report Patient Care Chart, it emphasizes planned interventions, expected outcomes, and ongoing assessments to achieve the best patient results.

Dos and Don'ts

When filling out the Report Patient Care Chart form, it's essential to get it right. Here's a handy list of what you should and shouldn't do.

Do: Ensure all fields are filled out completely.
Don't: Skip any questions, even if they seem less relevant.
Do: Verify patient information for accuracy to avoid errors.
Don't: Use vague terms; be specific in your descriptions.
Do: Record the time of events accurately to maintain a clear timeline.
Don't: Make assumptions; always stick to the facts as you know them.
Do: Review the form before submitting to catch any mistakes.

Adhering to these guidelines helps ensure quality patient care documentation and keeps everyone informed.

Misconceptions

Here are five common misconceptions about the Report Patient Care Chart form:

It is only necessary for emergencies. Many people believe that this form is required solely for emergency situations. However, it is also valuable for non-emergency patient care, ensuring all pertinent information is documented regardless of the scenario.
Anyone can fill it out. While it may seem straightforward, the Report Patient Care Chart should be completed by trained healthcare professionals. They have the necessary knowledge to accurately capture the information and ensure compliance with regulations.
It is irrelevant after treatment. Some assume that once a patient is treated, the form serves no purpose. In reality, the documentation is crucial for legal, insurance, and quality assurance purposes. It may be referred to later for follow-up care or investigations.
All details are optional. Many individuals think that only certain sections matter. In fact, numerous parts of the form hold significant weight. Completing all required fields accurately is essential for a comprehensive patient report.
It is only for paramedics or ambulance crews. This form is not limited to a specific type of healthcare provider. It can be used by various medical professionals in different settings, including hospitals and urgent care facilities. Anyone involved in patient care can benefit from utilizing it.

Key takeaways

Filling out and using the Report Patient Care Chart form is crucial for effective patient care and documentation. Here are some important takeaways that can help ensure accuracy and comprehensiveness:

The form is designed to gather essential details about the patient and the incident. Always ensure you complete every section relevant to the situation.
Be meticulous in recording the incident number and unit ID. These identifiers facilitate tracking and accountability.
Document the patient's full name, age, and gender as soon as possible. This information is vital for any further medical treatment.
Patient care categories like treatment dispositions are critical. Indicate how the patient was transported or treated after your encounter.
Be aware of significant factors such as current medications and allergies. This information can prevent potential adverse reactions during care.
Accurately note chief complaints and their associated symptoms. Clear communication about the patient's condition is essential for continuity of care.
Use the form to report any barriers to standard patient care that you encounter, in order to improve response strategies in the future.
Finally, complete the narrative section thoughtfully. This allows you to provide additional context not captured elsewhere, enhancing the overall understanding of the case.

Being thorough and accurate ensures everyone involved in the patient's care is on the same page, ultimately benefiting the patient.

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