Title Page
PATIENT INFO
PATIENT INFORMATION
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Select date
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Driver's License
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Name
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Address
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Date of birth
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Age
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Primary Physician
VITALS
VITALS
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Select date
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Pulse
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Blood Pressure
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O2 SAT
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Respirations
ASSESSMENT
ASSESSMENT
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Medical<br>SAMPLE History
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Chief Complaint
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Signs & Symtoms
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Allergies
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List
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Photo of list
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Medications
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List
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Photo of list
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Pertinent History
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Last Oral Intake
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Notes
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LAST Bowel Movement
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TRAUMA <br>DCAP BTLS
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Chief Complaint
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Signs & Symptoms
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Allergies
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List
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Photo of list
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Medications
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List
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Photo of list
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Loss of Consciousness
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Head or Neck Pain
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C-Spine Precautions
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MOTOR VEHICLE ACCIDENT
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Add media
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Type of Collision
- Rear End
- Side Impact
- Head On
- Frontal
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PT Location in Crash
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Seat Belt
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Helmet
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Airbags Deployed
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Vehicle Make and Model
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Add media
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Glasgow Coma Scale
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Right Eye
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Left Eye
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Skin
- Normal
- Dry
- Clammy
- Cold
- Warm
- Cyanoric
- Pale
- Diaphoretic
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Lung Sounds
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Notes
TREATMENTS
TREATMENTS
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IV THERAPY
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Select date
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Size & Location
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Blood Draw
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Oxygen
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Select date
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Delivery Method
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Rate (lpm)
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Advanced Airway
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Type
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Select date
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Monitor
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Method
- Patches
- 5 Lead
- 12 Lead
- ET CO2
- DEFIB
- Cardiovert
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MEDICATIONS
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Select Meds
- Oxygen
- D-50
- Narcan
- Epi 1:1000
- Glucagon
- Zofran
- Aspirin
- Albuterol
- Duo Neb
- Epi 1:10000
- Lidocaine
- Sodium bi carb
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CPR
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Successful Resuscitation?
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C-Spine
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BANDAGE
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Splint
SIGNATURES
Signatures
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Patient Refusal
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By signing the release, I agree that:
• I was offered transport to a hospital.
• The risks of refusing care and transport were explained to me.
• By refusing the care offered to me, I may increase the possibility of serious illness
or death.
• I was advised to seek medical attention.
• I was made aware of how to access follow-up care.
• I understand the directions given to me, and the risks involved with refusing
transport against the advice of EMTs.
• I am being left in the care of a responsible adult when appropriate.
Follow-up Care:
If there is a return of symptoms or you become concerned, you should do one of the following:
• Contact your primary care doctor or their on-call answering service.
• Call “911” and ask for an ambulance.
• Visit an Emergency Department or Medical Clinic. -
I hereby refuse treatment and/or transport to a hospital and I acknowledge that such treatment or transportation was advised by the emergency crew or physician. I hereby release such persons from liability for respecting and following my express wishes. -
Patient Signature
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Relationship
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Witness
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SHIFT
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Station
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Signature
