SIGNS/SYMPTOMS

INJURY TYPE

CONDITIONS

ECG

CIRCULATION

• SIGNS AND SYMPTOMS
  • Report signs and symptoms related to your patient’s current condition in this section.
  • Note that some signs and symptoms relate to both injury and medical patients.
  • Mark all responses that apply.
  • If your patient experienced signs or symptoms other than those listed, you should mark the "Other" response and note the signs or symptoms in the blank space provided at the bottom of the form.
    

• INJURY TYPES
  • Use the injury type section to report causes of injuries experienced by your patient.
  • Mark all responses that apply.
  • If you need to document an injury type other than those listed, mark the "Other" response and note the other injury type in the blank space provided at the bottom of the form.
    

• CONDITIONS
  • Mark the illness(es) or medical condition(s) contributing to your patient’s current need for pre-hospital care.
  • Mark all responses that apply.
  • To document a condition other than those listed, mark the "Other" response and note the other condition in the blank space provided at the bottom of the form.

• E.C.G.
  • Document your patient’s first (F) and last (L) electrocardiogram rhythms.
  • If you need to document a cardiac rhythm other than those listed, mark the "Other" response and provide a description in the blank space provided at the bottom of the form.
  • Document whether a three lead or twelve lead ECG was used by marking the appropriate response.
    

• CIRCULATION
  • IV 1 Attempt Mark this response (A) if the first or second attempt at establishing the first intravenous
    line was unsuccessful.

• IV 1 Success Mark the (S) response if the first intravenous line was successfully established.
  • Use the 1, 2, and 3 responses to indicate which providers were responsible for the first intravenous line attempts or success.
  • If two providers attempted to establish the first line and neither was successful, mark both provider numbers.
    If two providers attempted and only one was successful, mark only the number
    identifying the successful provider.
• IV 2 Attempt Mark this response (A) if the first or second attempt at establishing the second intravenous line was unsuccessful.
• IV 2 Success Mark the (S) response if the second intravenous line was successfully established.
  • Use the 1, 2, and 3 responses to indicate which providers were responsible for the second intravenous line attempts or success.
  • If two providers attempted to establish the second line and neither was successful, mark both provider numbers.
  • If two providers attempted and only one was successful, mark only the number identifying the successful provider.
• EJ (External Jugular) Attempt Mark the (A) response if external jugular placement was attempted, but not successful, for either the first or second intravenous fluid line.
• EJ (External Jugular) Success Mark the (S) response if external jugular placement was attempted and successful for either the first or second intravenous fluid line.
  • Use the 1, 2, or 3 responses to document which provider was responsible for the external jugular IV attempt or success.
  • If two providers attempted and only one was successful, mark only the number identifying the successful provider.
• IO (Intraosseous ) Attempt Mark the (A) response if intraosseous intravenous fluid line placement was attempted, but not successful, for either the first or second intravenous fluid line.
• IO (Intraosseous) Success Mark the (S) response if intraosseous placement of an intravenous fluid line was attempted and successful for either the first or second intravenous fluid line.
  • Use the 1, 2, or 3 responses to document which provider was responsible for the intravenous IV attempt or success.
  • If two providers attempted and only one was successful, mark only the number identifying the successful provider.
  • Record the amount (total CC’s) of intravenous fluids infused during pre hospital care in the boxes provided on the lower right corner of the form.
  • Record the anatomical site and needle gauge used in IV placement on the line provided at the bottom of the form.