Samaritan Shift Report
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SAMARITAN EMS SHIFT REPORT
Purpose: This report is used by Samaritan to summarize shifts. Shift reports are emailed to key Samaritan management and supervisory staff.
General Shift Details
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SHIFT DATE (Use the date shift started)
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Supervisor/Crew Member Reporting
Patient Refusals
PATIENT REFUSAL
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PCR Number
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Patient Name
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Description of Medical Complaint and Reason for non-transport
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PCR Number
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Patient Name
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Description of Medical Complaint and Reason for non-transport
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PCR Number
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Patient Name
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Description of Medical Complaint and Reason for non-transport
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PCR Number
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Patient Name
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Description of Medical Complaint and Reason for non-transport
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PCR Number
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Patient Name
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Description of Medical Complaint and Reason for non-transport
Vehicle Issues/Contacts
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Were there any vehicle issues, excluding vehicle contacts, during the shift?
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If Yes explain:
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Were there any vehicle contacts during the shift?
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If yes provide details:
Use the fields below to take or add pictures to document damage:
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Picture 1 of damage
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Picture 2 of damage
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Picture 3 of damage
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Picture 4 of damage
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Picture 5 of damage
Employee Injuries
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Were there any employees injured during this shift?
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If yes, who was hurt?
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What happened?
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Were they seen by the Hospital, concentras, or declined medical evaluation at this time
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If Hospital
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If yes, who was hurt?
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What happened?
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Were they seen by the Hospital, concentras, or declined medical evaluation at this time
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If Hospital
Incidents/Complaints
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Were there any incidents or complaints during this shift?
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What happened?
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Crew members involved?
Pass On Information
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Pass On Information: Please pass on any other details that need to be shared with other staff members, also if there is additional space need to document other issues please add here.
