Space has been provided at the bottom of the form to document the following information based on the care rendered to your patient:

SAO2: Record the patient’s saturated oxygen value based on Pulse Oximetry in the
boxes provided.
ET size: Record the Endotracheal tube size if you intubated the patient.
O2 lpm: Record the liters per minute of oxygen administered to the patient.
Total cc’s: Record the amount of intravenous fluids infused during prehospital care in the boxes provided.
Glucose: If you monitored the patient’s blood glucose with a glucometer, you should record the glucose level in the boxes provided.
Gauge/Site: Record the anatomical site(s) and needle gauge used for IV placement.
Mileage Record the number of miles driven for this call.
On-line Physician: Record the name of the physician who provided medical direction during radio consult.
Provider Signature: The provider considered to be the medically responsible provider among the crew should sign on the provider signature line.
Hospital Signature: Obtain the signature of an authorized hospital employee at the time you deliver your patient to the receiving facility. Protocols stipulate that the employee receiving the patient must be at least the same or higher level of training as the highest certified provider on the unit.
EMS Reviewer: The name of the individual reviewing the contents of the form should be recorded on the EMS reviewer line.

PROV # Documents which provider (1, 2, or 3) was responsible for the provision of care reported in this entry.
TIME: Military time corresponding to the time care was provided.
B.P.: Blood pressure at the time the FIRST B/P was taken on the first line, and the LAST B/P taken on the bottom line.
Pulse: Record the pulse rate at the time the FIRST pulse was taken on the first line, and the LAST time the pulse rate was taken on the bottom line.
Resp: Respiratory rate the FIRST time respirations were taken on the first line, and the LAST respiratory rate taken on the bottom line.
Rhythm: Rhythm from E.C.G. reading, if applicable.
Care Provided: Document other care such as administering medications here.
Amount: Use this space to document amounts of meds administered, etc.