EMR RESPONSE FORM

• Document No.

• EMR RUN SHEET

• Conducted on

  Date

• KYLE BLACK NREMT

Demographics

• Incident date

  Date

• Reported time

  Date

• Arrival on scene

  Date

• Patient Name

• Patient's Birthday

• Chief Complaint

• Onset time

  Date

• Medication Patient is taking

• Allergies patient has

• Patient vitals

• Patient AOx4

• Was AED USED?

  Yes

  No

  N/A

• If AED USED HOW MANY TIME DID IT TELL YOU SHOCK.

• Was CPR STARTED?

  Yes

  No

  N/A

• Was Ambulance needed?

  Select Yes No

  • Yes
  • No

• What is the GCS LEVEL

  Select obeys commands ( motor) purposeful movement with draws from pain flexion from pain extension from pain none oriented (verbal) confused inappropriate incomprehensible none spontaneous (eye movement) verbal stimuli painful stimuli none

  • obeys commands ( motor)
  • purposeful movement
  • with draws from pain
  • flexion from pain
  • extension from pain
  • none
  • oriented (verbal)
  • confused
  • inappropriate
  • incomprehensible
  • none
  • spontaneous (eye movement)
  • verbal stimuli
  • painful stimuli
  • none

• Is there possibility of etoh or drugs?

  Yes

  No

  N/A

• Delays in care or response

• Past Pertinent Medical History

  Select TRAUMA INJURY STROKE SYNCOPE RESPIRATORY ISSUES SEIZURES DIABETIC CARDIAC HISTORY OTHER NONE

  • TRAUMA INJURY
  • STROKE
  • SYNCOPE
  • RESPIRATORY ISSUES
  • SEIZURES
  • DIABETIC
  • CARDIAC HISTORY
  • OTHER
  • NONE

• Narrative

• Treatment and disposition

• Follow up with nurse

  Date

• Other responding staff

• EMT SIGNATURE

  Sign