WFD PCR

• Dispatch Complaint

• Scene Address

  Select

• Response Unit

  Select 1910 1911 1914 1912 1901 1902 1905 1906 1907 1909

  • 1910
  • 1911
  • 1914
  • 1912
  • 1901
  • 1902
  • 1905
  • 1906
  • 1907
  • 1909

• Personnel

  Select Ryan Pelletier AC Aaron Dupree AC Darrell Wright BC Randy Dupree Capt David Gilliland Capt Logan Lindamood Capt Brian Dunn Lt Jason Phillips Lt Cory Ireland Lt Ryan Souders FF Cole Sims FF Garrett Patton FF Andrew Henry FF Donnie Jarvis FF Gabe Cook

  • Ryan Pelletier
  • AC Aaron Dupree
  • AC Darrell Wright
  • BC Randy Dupree
  • Capt David Gilliland
  • Capt Logan Lindamood
  • Capt Brian Dunn
  • Lt Jason Phillips
  • Lt Cory Ireland
  • Lt Ryan Souders
  • FF Cole Sims
  • FF Garrett Patton
  • FF Andrew Henry
  • FF Donnie Jarvis
  • FF Gabe Cook

• Alert Time

  Date

• Responding

  Date

• Arrive Scene

  Date

• Arrive Patient

  Date

• Patient Care Transfer Time

  Date

• In Service & Returning

  Date

• Completed By

  Select Ryan Pelletier AC Aaron Dupree AC Darrell Wright BC Randy Dupree Capt David Gilliland Capt Logan Lindamood Capt Brian Dunn Lt Jason Phillips Lt Cory Ireland Lt Ryan Souders FF Cole Sims FF Garrett Patton FF Andrew Henry FF Donnie Jarvis FF Gabe Cook

  • Ryan Pelletier
  • AC Aaron Dupree
  • AC Darrell Wright
  • BC Randy Dupree
  • Capt David Gilliland
  • Capt Logan Lindamood
  • Capt Brian Dunn
  • Lt Jason Phillips
  • Lt Cory Ireland
  • Lt Ryan Souders
  • FF Cole Sims
  • FF Garrett Patton
  • FF Andrew Henry
  • FF Donnie Jarvis
  • FF Gabe Cook

• Care Transferred To (unit, name & certification level)

• Patient Name

• Date of Birth

  Date

• Social Security Number

• Address

• Phone Number

• Chief Complaint

Level of Consciousness

• Alert

  Verbal

  Pain

  Unresponsive
Vitals

• Vitals Must Be Completed

• Airway

  Patent

  Closed

  Obstructed

• Respirations

• Breath Sounds

  Select Clear / Equal Wheezing Rales Stridor Diminished Absent

  • Clear / Equal
  • Wheezing
  • Rales
  • Stridor
  • Diminished
  • Absent

• SpO2

• CO2 - Capnography

• Carbon Monoxide

• Pulse

• Pulse Quality

  Strong

  Bounding

  Thready

  Absent

• Blood Pressure

• Temperature

• Temperature Route

• Blood Glucose

• Pupils

  PERRL

  Non Reactive

  Unequal

  Classed

Signs and Symptoms

• undefined

• Onset

• Palliation/Provocation

  Yes

  No

• Quality

• Radiation

  Yes

  No

• Severity

  Select 0 of 10 1 of 10 2 of 10 3 of 10 4 of 10 5 of 10 6 of 10 7 of 10 8 of 10 9 of 10 10 of 10

  • 0 of 10
  • 1 of 10
  • 2 of 10
  • 3 of 10
  • 4 of 10
  • 5 of 10
  • 6 of 10
  • 7 of 10
  • 8 of 10
  • 9 of 10
  • 10 of 10

• Time

Allergies

• Yes

  No

Medications

• Yes

  No

Past Pertinent Medical History

• Yes

  No

Last Oral Intake

• undefined

Events Leading Up To

• undefined

Procedures

• Procedure

  Select IV OPA NPA Supraglottic Airway CPR Defibrillation EKG Bandaging Tourniquet Splinting Spinal Immobilization Full Body Immobilization KED Eye Irrigation Wound Irrigation Bleeding Control Wound Packing

  • IV
  • OPA
  • NPA
  • Supraglottic Airway
  • CPR
  • Defibrillation
  • EKG
  • Bandaging
  • Tourniquet
  • Splinting
  • Spinal Immobilization
  • Full Body Immobilization
  • KED
  • Eye Irrigation
  • Wound Irrigation
  • Bleeding Control
  • Wound Packing

• Did Procedure Help?

  Yes

  No

• Crew Member Performing

  Select Ryan Pelletier AC Aaron Dupree AC Darrell Wright BC Randy Dupree Capt David Gilliland Capt Logan Lindamood Capt Brian Dunn Lt Jason Phillips Lt Cory Ireland Lt Ryan Souders FF Cole Sims FF Garrett Patton FF Andrew Henry FF Donnie Jarvis FF Gabe Cook

  • Ryan Pelletier
  • AC Aaron Dupree
  • AC Darrell Wright
  • BC Randy Dupree
  • Capt David Gilliland
  • Capt Logan Lindamood
  • Capt Brian Dunn
  • Lt Jason Phillips
  • Lt Cory Ireland
  • Lt Ryan Souders
  • FF Cole Sims
  • FF Garrett Patton
  • FF Andrew Henry
  • FF Donnie Jarvis
  • FF Gabe Cook

• Crew Member Level of Certification

  EMR

  EMT

  Advanced EMT

  Paramedic
Medication Administration

• undefined

  Select Aspirin Normal Saline .9 D50 Glucose Nitroglycerin Diphenhydramine Zofran

  • Aspirin
  • Normal Saline .9
  • D50 Glucose
  • Nitroglycerin
  • Diphenhydramine
  • Zofran

• Administrative Route

  Select Oral IV Nasal IM Sub Q Skin

  • Oral
  • IV
  • Nasal
  • IM
  • Sub Q
  • Skin

• Did Medication Help

  Yes

  No

• Crew Member Administering

  Select Ryan Pelletier AC Aaron Dupree AC Darrell Wright BC Randy Dupree Capt David Gilliland Capt Logan Lindamood Capt Brian Dunn Lt Jason Phillips Lt Cory Ireland Lt Ryan Souders FF Cole Sims FF Garrett Patton FF Andrew Henry FF Donnie Jarvis FF Gabe Cook

  • Ryan Pelletier
  • AC Aaron Dupree
  • AC Darrell Wright
  • BC Randy Dupree
  • Capt David Gilliland
  • Capt Logan Lindamood
  • Capt Brian Dunn
  • Lt Jason Phillips
  • Lt Cory Ireland
  • Lt Ryan Souders
  • FF Cole Sims
  • FF Garrett Patton
  • FF Andrew Henry
  • FF Donnie Jarvis
  • FF Gabe Cook

• Crew Member Certification Level

  EMR

  EMT

  Advanced EMT

  Paramedic
Oxygen Administration

• Route

  N/A

  Nasal Cannula

  Non Rebreather

  Bag Valve Mask

  Nebulizer

• Administered Rate

  Select N/A 2 LPM 3 LPM 4 LPM 5 LPM 7 LPM 10 LPM 15 LPM 25 LPM

  • N/A
  • 2 LPM
  • 3 LPM
  • 4 LPM
  • 5 LPM
  • 7 LPM
  • 10 LPM
  • 15 LPM
  • 25 LPM

• Did Oxygen Help?

  Yes

  No

• Crew Member Administering

  Select N/A 2 LPM 3 LPM 4 LPM 5 LPM 7 LPM 10 LPM 15 LPM 25 LPM

  • N/A
  • 2 LPM
  • 3 LPM
  • 4 LPM
  • 5 LPM
  • 7 LPM
  • 10 LPM
  • 15 LPM
  • 25 LPM

• Crew Member Certification Level

  EMR

  EMT

  Advanced EMT

  Paramedic

Narrative

• undefined

Patient - Consent to Treatment

• Does Patient Consent to Treatment?

  Yes

  No

• Patients Signature

  Sign

• Was patient unable to sign?

  Yes

  No

• How was consent given

  Verbal

  Implied

  Advanced Order

  Medical Power of Attorney

• Witness Signature (non crew member)

  Sign
Crew Member Signatures

• Crew Member

  Sign

• Crew Position

  In Charge

  Crew Member

• Certification Number

• Level of Certification

  EMR

  EMT

  Advanced EMT

  Paramedic