Instruction Manua Illinois EMS Preho Care Report Form
Transcript of Instruction Manua Illinois EMS Preho Care Report Form
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State of Illinois
Pat Quinn, Governor
Department of Public Health
Damon T. Arnold, M.D., M.P.H., Director
Instruction Manual for the
Illinois EMS PrehospitalCare Report Form
Form Version Dated April 2010
May 2010
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RecordofChangestothisDocument
ChangeDate Description Location
April2010 Initialrelease N/A
12May2010 Thedestinationhospitaltableisnowsortedbyhospitalnamerather
thanIDnumberandanewdestinationhasbeenadded(Deaconess
GatewayHospital,Newburgh,IN).
AppendixD
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InstructionManualfortheIllinoisEMSPrehospitalCareReportForm
Contents
Section1: TheLegalBasisforCollectingPrehospitalData....1
Section2:
General
Guidance2
Section3: ElementbyelementGuidance..3
Section4: Appendices
AppendixA: IllinoisCountyCodes.12 AppendixB: CodesforOutofstateCountiesBorderingIllinois..13 AppendixC: EMSSystemNumbersandResourceHospitalNamesandCities14 AppendixD: DestinationHospitalIDs,Names,andCities...15 AppendixE: Form..19
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IllinoisPrehospitalCareReportFormInstructionManualVersion1.1,May2010
IllinoisDepartment
of
Public
Health,
Division
of
EMS
and
Highway
Safety
1
Section1TheLegalBasisforCollectingPrehospitalData
TheIllinoisDepartmentofPublicHealthisauthorizedbytheIllinoisEMSAct,210ILCS50/3.195,andthe
EmergencyMedicalServiceandTraumaCenterCode,77IAC 515.350,tocollectprehospitalrunreportdata.
Fromthe
EMS
Act
(210
ILCS
50)
3.195.DataCollectionandEvaluation.
(a)TheDepartmentshalldevelopandadministeranemergencymedicalservicesdatacollectionsystem.
NothinginthisSectionshallbeconstruedtoempowertheDepartmenttospecifytheformofinternal
recordkeeping.
(b)TheconfidentialityofpatientrecordsshallbemaintainedinaccordancewithStateandfederal
regulationsonconfidentialityofrecords.
(c)TheDepartmentshalldevelopparametersbywhichtheavailabilityandqualityofemergencymedical
carecanbeevaluatedtoassureareasonablestandardofperformancebyindividualsandorganizations
providingsuchservices.
(d)EMSMedicalDirectorsshallhavetheauthoritytorequireSystemparticipantstoprovidedatatothe
SysteminadditiontothatrequiredbytheDepartment.Participantsshallnotberequiredtosubmit
financialinformationthatisproprietaryinnatureandunrelatedtothescopeorpurposesofthisAct.
FromIllinoisAdministrativeCode(77IAC)
515.350(excerpts)
a) Arunreportshallbecompletedbyeachvehicleserviceproviderforeveryemergencyprehospitalor
interhospitaltransportandforrefusalofcare.
1) Onecopyshallbeleftwiththereceivinghospitalemergencydepartment,traumacenteror
healthcare
facility
before
leaving
this
facility.
2) EachResourceHospitalEMSSystemshalldesignateorapproveasingleformtobeusedbyallof
itsvehicleproviders. Itshallbeaformthatcontainstheminimumprescribeddataelements
listedinSection515.AppendixEofthisPart.
/========================================================================/
c) TheambulanceprovidershallsubmittherunreportdatatotheResourceHospitalEMSSystem. Each
ResourceHospitalEMSSystemshallsubmitadatareporttotheDepartmentonMarch1,June1,
September1,andDecember1ofeachyear,coveringrunreportdatafromtheprecedingquarter. The
reportshallbeinoneofthefollowingformats:
1)
Copiesof
ascannable
run
report
form,
or
2) [Anelectronicfile]containingtheprescribeddataelements.
A) ThedataelementsshallbeinaformatcompatiblewiththeDepartment'sdatabaseinput
specifications,and
B) Departmentreviewandapprovalofdataformatcompatibilityisrequiredpriorto
submission.
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IllinoisPrehospitalCareReportFormInstructionManualVersion1.1,May2010
IllinoisDepartment
of
Public
Health,
Division
of
EMS
and
Highway
Safety
2
Section2GeneralGuidance
Theseinstructionsapplytotheonepage,twosidedcomputerformusedtocollecttheprehospitaldata
elementsprescribedbytheIllinoisDepartmentofPublicHealth. Thisformiscommonlyreferredasthe
bubblesheet.
Generalguidelinesforthesuccessfulcompletionandshipmentoftheforms:
Useblackorblueinktofillinthebubbles. Redink,inparticular,willnotberecognizedbythescanner. Errorsmaybecoveredusingcorrectionfluidorcorrectiontape. Iffluidisuseditshouldbeallowedtodry
completelybeforestackingtheforms.
Fillovalscompletely. Doughnuts,checkmarks,orsinglelinesthroughanovalwillnotberecognizedbythescanner.
Donottear,fold,orotherwisedamagetheform. Donotstapleotherdocumentstotheform,suchasnarrativedocumentation,orincludeotherloose
documentswiththeformsshipment;ensureallformsarefreeofstaples.
Donotwriteintheformmargins,oranywhereelseontheformexceptintheboxesandovalsdirectlyunderneath
each
of
the
blue
and
white
data
element
labels.
Ensurethattheformsaresecurelypackagedforshipping,especiallyiftheyarebeingsentbythecarton.Thiswillminimizeshippingdamagesuchascurledorcreasededges,tears,andformsthatdonotlieflat.
SendtheformstotheappropriateEMSSystemResourceHospitalor,withtheResourceHospitalspermission,directlytotheIllinoisDepartmentofPublicHealth:
IDPH/OPR/EMSandHighwaySafety
122SMichiganAve,Rm768
Chicago,IL60603
Attn: PrehospitalReportForms
Allreportsforrunsthatoccurinagivenquartershouldbepromptlyshippedaftertheendofthatquarter.Formsmaybesentmorebutnotlessoftenthanquarterly.
Additionalinformationabouttheform:
Whenadataelementcontainsheaderboxesabovecolumnsofovals,entertextintheboxesandfillintheovalbelowitthatcorrespondstothetextentry.
UnknownandNotApplicableresponsesareintendedonlyforuseinsituationsforwhichthosedescriptionstrulyapply. Theyshouldnotbeusedwhenmorespecificinformationisavailableand
applicable.
Whenenteringanumber,suchasatime,allavailablecolumnsforthenumbermustbecompleted,includingleadingzeros. Ifthetimetobeenteredis8:05AM,thecorrectentryis0805. Usemilitarytime,
sofor8:05PMthecorrectentryis2005.
Somedataelementswithmultiplechoicesallowmultipleentries,whileotherothersallowonlysingleentries. Refertotheelementbyelementinstructionsinthenextsectionformoreinformation.
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Section2ElementbyelementGuidance
Specificvalues/choicesformultiplechoicedataelementsarenotdefinedwhenselfevidentorassumedto
becommonknowledge.
Unlessotherwisenoted:
Anentryisrequiredforeachapplicabledataelementontheform; Onlyoneresponseshouldbeselectedformultiplechoicedataelements.
SideoneofformLITHOCODE: Theformserialnumberpreprintedonsideone,lowerrighthandside(noentryneeded).
DATE: Themonth,date,andyearthattheEMSresponsewasinitiated. Recordonlythelastdigitofthe
year.
AGENCYNO.: ThefourdigitEMSproviderlicensenumber(thefirstfourdigitsofthevehicleplatenumber).
Entrieswillbecheckedagainstknownagencylicensenumberswhentheformisscanned.
AvalidEMSagencylicensenumbermustberecordedonallrunreports,regardlessof
patient/incidentdisposition,includingcancellationsandrefusals.
VEH.#:The
two
digit
EMS
vehicle
number
(the
last
two
digits
of
the
vehicle
plate
number).
INCIDENTNUMBER: Thenumberassignedtotheincidentbythe911dispatchsystem.
INCIDENTCOUNTY: Enterthe5digitFederalInformationProcessingStandards(FIPS)codeforthecountyin
whichtheincidentoccurred. Thelastthreeofthefivedigitscomprisethecountyidentifier,andthefirsttwo
comprisethestateidentifier. ThestateidentifierforIllinoisis17. Forsurroundingstatesthestate
identifiersare:
Indiana18 Iowa19 Kentucky21 Missouri29 Wisconsin55
INCIDENTZIPCODE: ThefivedigitZIPcodefortheareainwhichtheincidentoccurred.
DISPATCHDELAY: Thereasonforadelayduringdispatch;ifnodispatchdelayselectNone.
DELAYS: ThismatrixcoversRESPONSEDELAY,SCENEDELAY,andTRANSPORTDELAY. Iftherewasadelay
duringone
or
more
of
these
stages
of
the
run
select
the
choice
in
the
appropriate
row
that
best
describes
thereasonforthedelay;wheneverthereisnodelayforastage,selectNoneforthatstage;recordN/A
forSCENEDELAYorTRANSPORTDELAYifeithertypeofdelaydoesnotapplyduetoacallcancellation,no
patientfoundatscene,etc.
TURNAROUNDDELAY: ReasontheEMSunitexperiencedadelayinachievingastateofreadinessforthe
nextcall;ifnoturnarounddelayselectNone.
RESPONSEMODE: Theunitslightsandsirensstatusonthewaytothescene.
SERVICEREQUESTED: TypeofservicetheEMSunitwasdispatchedtoprovide.
911Response(Scene)Emergentorimmediateresponsetoanincidentlocation,regardlessofmethodof
notification(forexample,911,directdial,walkintoagency,orflaggingdown).
Intercept
When
one
EMS
Provider
meets
atransporting
EMS
unit
with
the
intent
of
receiving
apatient
or
providingahigherlevelofcare.
InterfacilityTransferTransferofapatientfromonehospitaltoanotherhospital.
MedicalTransportAtransportthatisnotbetweentwohospitalsanddoesnotrequireanimmediate
response.
MutualAidArequestfromanotherambulanceservicetoprovideemergentorimmediateresponsetoan
incidentlocation.
StandbyAninitialrequestforservicethatwasnottiedtoapatientbuttoasituationwhereapersonmay
becomeillorinjured,suchasaparade,sportsevent,orotherlargepublicgathering.
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COMPLAINTREPORTEDBYDISPATCH: Theprimarycomplaintprovidedtotheunitbythe911dispatcher.
EMDPERFORMED: WhetherornotEmergencyMedicalDispatching(EMD)wasperformedbythe911
dispatcherand,ifso,whetherornotprearrivalinstructionswereprovidedtotheunit.
GENDER: Patientgender;completeYforpregnantwhenapplicable.
ETHNICITYandRACE: Theseareseparatecategoriesandbothfieldsshouldbecompleted. Baseselections
onwhatisselfreportedbythepatient,wheneverpossible.
PTDATEOFBIRTH: IfUNKisselectedforpatientdateofbirththenanestimateisrequiredinAGE. An
exactdateofbirthispreferabletoanestimateintheAGEfield.
WORKRELATED:Basetheresponseoninformationprovidedbythepatientorwitness. Ifthatisnot
available,anEMScrewmembersassessmentmaybeusediftheworkrelatedstatusisnotinquestion.
PTsOCCUPATIONALINDUSTRY: CompleteifWORKRELATEDisYes,otherwiseleaveblank.
AGE: AnentryisrequiredifnobirthdateisrecordedinthePT.DATEOFBIRTHfield,otherwiseAGEmaybe
leftblank. Alwayscompleteallthreedigits(forexample,16yearswouldbe016,2yearswouldbe002);
unitsarerecordedherealso. Usehours,days,months,oryearsasfollows:
Ifageislessthanoneday,usehours;otherwise Ifageislessthanonemonth,usedays;otherwise Ifageislessthantwoyears,usemonths;otherwise Forallotheragesuseyears.
PT.HOMEZIPCODE: Maybeleftblankifnotapplicable,suchaswithacancelledcallorifnopatientis
foundatthescene.
CREWMEMBER#1/#2/#3ID: ThestatelicensenumberforeachEMTB/I/Pcrewmemberassociatedwith
theEMSunitforwhichthereportisbeingcompleted,foruptothreecrewmembersbeginningwithCREW
MEMBER#1ID. Iffewerthanthreecrewmembers,leavetheremainingfield(s)blank. Entrieswillbe
checkedagainstvalidEMTB/I/Plicensenumberswhentheformisscanned.
INCIDENTLOCATIONTYPE: Thesettinginwhichtheincidentoccurred.
Home/Residence
Any
home,
apartment,
or
residence
(not
just
the
patient's
home).
Includes
ayard,
driveway,
garage,pool,garden,orwalkofahome,apartment,orresidence. Excludesassistinglivingfacilities.
FarmAplaceofagriculture,excludingafarmhouse;includeslandundercultivationandnonresidential
farmbuildings.
MineorQuarryIncludessandpits,gravelpits,ironorepits,andtunnelsunderconstruction.
IndustrialPlaceandPremisesAplacewherethingsaremade,assembled,constructed,stored,or
loaded/unloaded;includesconstructionsites,factories,warehouses,industrialplants,docks,andrailway
yards.
PlaceofRecreationorSportIncludesamusementparks,publicparksandplaygrounds,sports
fields/courts/courses,sportsstadiums,skatingrinks,gymnasiums,nonresidentialswimmingpools,
waterparks,andresorts.
StreetorHighwayAnypublicstreet,road,highway,oravenue,includingboulevards,sidewalks,ditches.
PublicBuilding(schools,governmentoffices)Anypubliclyownedbuildinganditsgrounds,including
schools,publicmuseums,andgovernmentoffices.
TradeorService(business,bars,restaurants,malls,etc.)Anyprivatelyownedbuildingusedforbusiness
andopentothepublic. Includesbars,restaurants,officebuildings,churches,stores,malls,bus/railway
stations. Excludeshealthcarefacilities.
IncidentLocationTypecontinuedonnextpage
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INCIDENTLOCATIONTYPE(continued):
HealthCareFacility(clinic,hospital,nursinghome)Aplacewherehealthcareisdelivered,includes,clinics,
doctor'soffices,hospitalsand,undercertainconditions,nursinghomes*.
ResidentialInstitution(nursinghome,assistedliving,jail/prison)Aplacewherepeoplelivethatisnota
privatehome,apartment,orresidence. Includes,nursinghomes*,jails/prisons,orphanages,assistedliving
whenamedicalcareproviderisavailablebutdoesnotprovidepatientcareonaregularbasis,andgroup
homes.
Lake,River,OceanAnybodyofwater,exceptswimmingpools.
OtherLocationAnyplacethatdoesnotfitoneoftheabovecategories(useofthisselectionshouldbevery
rare).
#OFPTSATSCENE: UseMultipleEMSOverwhelmedtoindicateamasscasualtyincident(MCI). Forthe
purposesofthissystem,amasscasualtyincidentisaneventwhichincreasespatientvolumetotheextent
thatlocallyavailableemergencyandhealthcareresources,usingroutineprocedures,arerendered
inadequateandnonroutineassistancebecomesnecessary.
POSSIBLEINJURY: IndicateswhetherornotthereasonfortheEMSencounterwasrelatedtoeitheran
actualinjuryorananticipatedinjurybasedonmechanism(mechanismofinjuryhasbeendescribedasthe
wayinwhichthepersonsustainedtheinjury;howthepersonwasinjured;theprocessbywhichtheinjury
occurred,or;theeventsleadingtotheinjurysituation). Maybeleftblankonlyifnotapplicable,suchaswith
acancelledcallorifnopatientwasfoundatthescene.
INC.ONSET: Ifavailable,thefourdigitmilitarytime(24hourtime)whentheincident/injuryoccurredorthe
symptoms/problembegan,orareasonablyaccurateestimate. Exampleofmilitarytimeusage: For8:05AM,
record0805;for8:05PM,record2005. Maybeleftblank,buttrytoavoidthat. Incidentonsettimeis
importantclinicalinformation,especiallyforstroke,cardiac,andtraumapatients.
PSAPCALL: Ifavailable,thefourdigitmilitarytimewhenthepublicsafetyansweringpointreceivedthe911
call,orareasonablyaccurateestimate. Maybeleftblankifunknown,buttrytoavoidthatiftheinformation
isavailable.
UNITNOTIFIED: ThefourdigitmilitarytimewhentheEMSunitwasnotifiedoftheincidentbydispatch.
Mustbecompletedforallcalltypes.
UNITENROUTE: ThefourdigitmilitarytimewhentheEMSunitstartedgotunderway(vehiclestarted
moving). Mustbecompletedforallcalltypes.
UNITARRIVED: ThefourdigitmilitarytimewhentheEMSunitarrivedatthesceneoftheincident(vehicle
stoppedmoving). Maybeleftblankonlyifnotapplicable,suchaswithacallcancelledenroute.
ATPT.: ThefourdigitmilitarytimewhentheEMSunitarrivedatthepatientsside. Maybeleftblankonlyif
notapplicable,suchaswithacancelledcallorifnopatientwasfoundatthescene.
LEFTSCENE: ThefourdigitmilitarytimewhentheEMSunitleftthesceneoftheincident(vehiclestarted
moving). Requirediftherespondingunittransportedthepatient.
ARRIVEDDEST.:
The
four
digit
military
time
when
the
EMS
unit
arrived
with
the
patient
at
the
destination
ortransferpoint(vehiclestoppedmoving). Requirediftherespondingunittransportedthepatient.
BACKINSRVC: ThefourdigitmilitarytimewhentheEMSunitwasfinishedwiththecall,backinservice,
andavailableforthenextresponse(butnotnecessarilybackinitshomelocation). Mustbecompletedfor
allcalltypes.
*Iftheincidentoccursatanursinghomeandthepatientisalongtermresidentthere,thenselectResidentialInstitution;ifthe
incidentoccursatanursinghomeandthepatientisreceivingrehabilitationservicesorotherhealthcareandisnotalongterm
resident,thenselectHealthCareFacility.
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Highway
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BACKATHOME: ThefourdigitmilitarytimewhentheEMSunitwasbackinitsservicearea. Leaveblank
whentheunitdoesnotreturntoitsserviceareabetweencalls.
PRIMARYMETHODOFPAYMENT: BaseselectiononhowtheEMSproviderwillbereimbursedforthe
incidentratherthanonthetypeofinsurancethepatienthas.
CommercialInsurance Theincidentwillbebilledtoacommercialinsuranceplansuchashealthinsurance
orautoinsurancethatispaidforprivatelybythepatient,thepatientsfamily,orthepatientsemployer
(excludingWorkers
Compensation).
Medicaid TheincidentwillbebilledtoMedicaid,thestate/federalprogramthatpaysformedicalassistance
forindividualsandfamilieswithlowincomesandresources.
Medicare TheincidentwillbebilledtoMedicare,thefederalhealthinsuranceprogramforpeople65and
older,orpersonsunder65withcertaindisabilities.
OtherGovernment(notMedicare,Medicaid,orWorkersCompensation) Theincidentwillbebilledtoa
governmentinsurancepolicybesidesMedicare,Medicaid,orWorkersCompensation.
SelfPay/PatientHasNoInsurance Theincidentwillbebilledtothepatientdirectly,orthepatienthasno
insurancepolicythatwillpayforthisincident.
NotBilled(foranyreason) Thepatientwillnotbebilledatallforthisincident.
Unknown Theprimarymethodofpaymentwasnotknownatthetimetheprehospitalcaredatasheetwas
completed.
CMSSERVICELEVEL: CentersforMedicare&MedicaidServiceslevelofservice(airorground). Base
selectiononthemedicallynecessarytreatmentprovidedduringtransport(notethatgroundreferstoboth
landandwatertransportation).
Ground
BasicLifeSupport(BLS)
BLS,Emergency
AdvancedLifeSupport,Level1(ALS1)
ALS,Level1,Emergency
AdvancedLifeSupport,Level2(ALS2)
SpecialtyCareTransport(SCT)
Paramedic
ALS
Intercept
(PI)
Air
FixedWingAirAmbulance(Airplane)
RotaryWingAirAmbulance(Helicopter)
UseTBD(ToBeDetermined)ifCMSServiceLevelistobedeterminedafterthecompletionofthe
prehospitaldatasheet.
FormoreinformationaboutCMSServiceLevels,includingdefinitions,seeMedicareBenefitPolicyManual,
Chapter10AmbulanceServices,Subsection30.1CategoriesofAmbulanceServices(accessedat
http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdfon20June2009).
CONDITIONCODE: UsedbytheEMSproviderservicetocommunicatethepatientscondition,(asobserved
bytheambulancecrew)toaMedicarecontractororotheroversightauthority. Whereapplicable,select
eitherBLSorALSormajor(MAJ)orminor(MIN). Selectallthatapply.
Thefollowingtensituationrelateddataelements(precededby(S)inthismanual)maybeleftblankonlyif
notapplicable,suchaswithacancelledcallorifnopatientwasfoundatthescene.
(S)PRIORAID: Type(s)ofcareprovidedtothepatientbeforetheunitarrivedatthescene. Selectallthat
apply. Therearetworelateddataelements:
(S)PERFORMEDBY: Categoriesofpeoplewhoprovidedprioraid. Selectallthatapply.
(S)OUTCOME: Theoveralloutcomeofallprioraidreceivedbythepatient. Selectonlyone.
(S)CHIEFCOMPLAINTANATOMICLOCATION: Theprimaryanatomiclocationofthepatientschief
complaint,asidentifiedbyEMSpersonnel.
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(S)CHIEFCOMPLAINTORGANSYSTEM: Theprimaryorgansystemofthepatientschiefcomplaint,as
identifiedbyEMSpersonnel.
(S)SYMPTOMS(PRIMARY&OTHER): SymptomsobservedbyEMSpersonnel.
ThepatientsprimarysymptomisindicatedusinganovalcontainingtheletterP. Selectonlyone. Thepatientsothersymptom(s)is/areindicatedusingoneormoreovalscontainingtheletterO. Selectasmany
asapply.
Sidetwoofform(S)PROVIDERsIMPRESSION(PRIMARY&SECONDARY): EMSpersonnelsimpressionoftheprimaryand
secondaryproblems/conditionsleadingtothemedications,procedures,and/orothertreatmentprovidedto
thepatient.
EMSpersonnelsprimaryimpressionisindicatedusingoneoftheovalscontainingtheletterP. Selectonlyone. EMSpersonnelssecondaryimpressionisindicatedusingoneoftheovalscontainingtheletterS. Selectonly
one.
(S)MEDICALHISTORYOBTAINEDFROM: Categorizesthesourceofthepatientsmedicalhistory.
(S)BARRIERSTOPATIENTCARE: Selectallthatapply.
(S)ALCOHOL/DRUGUSEINDICATORS: Documentsthepresenceofpotentialdrugoralcoholuseindicators
associatedwith
the
patient;
not
intended
to
document
whether
EMS
personnel
knew
with
certainty
that
the
patientwasaffectedbydrugsand/oralcoholatthetimeoftheincident. Selectallthatapply.
IftheselectionforthePOSSIBLEINJURYdataelementisYesthenthefollowingtwodataelements
(precededby(I)inthismanual)mustalwaysbecompleted.Also, iftheselectionforthePOSSIBLEINJURY
dataelementisYesandtheselectionforCAUSEOFINJURYiseitherMotorvehicletrafficaccidentorMotor
vehiclenontrafficaccident,thenthefivedataelementsprecededby(IMVA)inthismanualmustbealsobe
completed.
(I)CAUSEOFINJURY: Thecategoryofthereportedorsuspectedcauseofinjury. Selectonlyone. If
multiplecausesapply,choosetheonemostcloselyrelatedtotheprimaryreasonfortheresponseand/or
thetype
of
care
given.
ForamotorvehicleincidentoccurringonapublicroadorhighwayselectMotorvehicletrafficaccident; ifthe
incidentoccursentirelyoffofpublicroadwaysorhighwaysselectMotorvehiclenontrafficaccident.
SelectBicycleAccidentwhenamotorizedvehicleisnotinvolved;foraccidentsinvolvingamotorvehicleandabicycleselecteitherMotorvehicletrafficaccidentorMotorvehiclenontrafficaccidentbasedonwhetherornot
theincidentoccurredonapublicroad/highway.
Foradrowning/neardrowningrelatedtowatercraftselectWaterTransport;forotherdrowning/neardrowningincidentsselectDrowning.
RadiationExposureexcludescomplicationsofradiationtherapy.(I)USEOFOCCUPANTSAFETYEQUIP.: Safetyequipmenttype(s)inusebythepatientatthetimeofthe
injury. Selectallthatapply.
(IMVA)AIRBAGDEPLOYMENT: Whetheranairbagwaspresent;ifpresent,whetheritdeployed;if
deployed,whattype(s). MultipleselectionsallowedundertheDeployedsubheadingonly.
(IMVA)VEHICULARINJURYINDICATORS: Physicalevidenceassociatedwiththevehicleinvolvedinthe
motorvehicleaccidentcausingtheinjury. Theseindicatorsarerelatedtoinjurypatternsandhaveaclinical
application. Selectallthatapply.
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(IMVA)POSITIONOFPT.INVEHICLE: Twopiecesofinformationarecollectedinthisfield.
Thepatientsseatrowlocationinthevehicleatthetimeofthecrash;thesystemrecognizesupto50seatrows(01through50)toaccommodatevans,buses,etc;thefrontseatrowis01;todesignatea
cargoareaenteranynumbergreaterthan50.
Thepatientlocationwithinaseatrowatthetimeofthecrash: left(nondriver),right,middle,driver).(IMVA)LAWENFORCEMENT/CRASHREPORTNUMBER: Theuniquenumberassociatedwiththelaw
enforcement/crash
report
associated
with
the
incident.
Important
for
crash
outcome
data
linkage.
CARDIACARREST: Whetherornotthepatientexperiencedacardiacarrestand,ifso,whetheritoccurred
beforeorafterthearrivalofanEMSunit. Asindicatedintheshadedboxbelow,ifaYesvalueisselected
forthisdataelementthenthefiveothercardiacelementsmustbecompleted.
IftheresponsefortheCARDIACARRESTdataelementisoneofthetwoYesvaluesavailableforthat
elementthenthefivecardiacdataelementsprecededby(C)inthismanualmustbecompleted. Ifthe
responsefortheCARDIACARRESTdataelementisNothenthesefiveelementsleftblank.
(C)CARDIACARRESTETIOLOGY: Theproximatecauseofthecardiacarrest.
(C)ANYRETURNOFSPONTANEOUSCIRCULATION: AppliestoanytimeduringtheEMSevent.
(C)RESUSCITATION
ATTEMPTED:
Whether
resuscitation
was
attempted;
ifso,
what
type;
if
not,
why
not.
Selectallthatapply.
(C)ARRESTWITNESSEDBY: Whetherarrestwaswitnessedand,ifso,whetherbyahealthcareprovideror
layperson.
(C)FIRSTMONITOREDRHYTHMOFTHEPATIENT: Documentsthefirstmonitoredrhythmafteracardiac
arrest.
CARDIACRHYTHM: ThecardiacrhythminterpretedbyEMSpersonnelaspartofaroutinepatient
assessment. Thiselementispartofvitalsignsandisnotoneofthecardiacarrestelements. UsetheFIRST
MONITOREDRHYTHMOFTHEPATIENTdataelementtorecordthefirstcardiacrhythmidentifiedaftera
cardiacarrest.
Alwaysenterathreedigitnumberwhenrecordingdataforthefollowingfivevitalsignsdataelements;usea
leadingzeroifnecessary(e.g.,forapulserateof72,record072);ifaparticularvitalsignwasnottaken,
leaveitblank:
SYSTOLIC(mmHg)
DIASTOLIC(mmHg)
PULSE(perminute)
PULSEOX(percentage)
RESPIRATION(perminute)
WEIGHT: Athreedigitestimatedpediatricbodyweightmustberecordedforpatientsyoungerthan16(use
aleadingzeroifnecessary);provideanestimateiftheactualweightisunknown. Selectunits(poundsor
kilograms;kilogramsarepreferred).
GLASGOWCOMASCALE: Entriesmustberecordedforallthreecomponentscores(eye,verbal,motor)forthesystemtocalculateatotalscore.
Fortheverbalcomponenttherearethreeseparatesetsofvalues,oneforpatientslessthan2yearsold,oneforpatients25yearsolder,andoneforpatientsolderthan5. Usethesetofvaluesthatis
appropriateforthepatientsage.
Ifselectingascoreof6forthemotorcomponent,choseeither6a(patientisolderthan5years)or6b(patientisfiveyearsoryounger).
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STROKESCALE: Performedwhenastrokeissuspected. Selectthetypeofstrokescale(CincinnatiorLA)
andtheresultsoftheassessment. Ifanassessmentisnotcompletedbecauseastrokeisnotsuspected,
selectN/A.
THROMBOLYTICSCREEN: Indicatecontraindicationstothrombolyticusebasedonpatientscreening. Select
N/Aifdeemedunnecessary. SelectUnknownifavailableinformationwasinsufficientforscreening.
The
three
medication
data
elements
preceded
by
(M)
in
this
manual
must
be
completed
when
a
medication
is
giventothepatientbyEMSpersonnel. Ifnomedicationwasgivenallthreeoftheseelementsshouldbeleft
blank.
(M)MEDICATIONGIVEN&ADMINISTEREDROUTE: ThemedicationsgiventothepatientbyEMS. Selectall
thatapply.
Selectallmedicationsgivenbyfillingintheovaltotherightofthemedicationnamecontainingtheadministrationrouteabbreviation. Theroutesavailableforeachmedicationweredeterminedbythe
StateofIllinoisEMSMedicalDirectorandEMSandHighwaySafetyDivisionChiefusinggenerally
acceptedreferencematerials.
SelectanadministrationrouteforOtherifamedicationgiventothepatientisnotlistedamongthoseon
the
form.
ThefollowingmedicationroutetableisalsoprintedontheformnexttotheROUTELEGENDheading:ET=Endotracheal
IH=Inhalation
IM=Intramuscular
IN=Intranasal
IO=Intraosseous
IV=Intravenous
PO=Peros(bymouth)
RCT=Rectal
SC=Subcutaneous
SL=Sublingual
TOP=Topical
Ifthereisamedicationcomplication,fillintheovalcontainingtheletterCtotheleftofnameofthemedicationassociatedwiththecomplication. Indicate,atmost,onlyonemedicationcomplicationper
runreport.Iftherearecomplicationsassociatedwithmorethanonemedication,fillintheCovalonly
forthemedicationassociatedwiththemostseriouscomplication.
(M)MEDICATION
COMPLICATION:
If
amedication
complication
was
identified
by
filling
in
the
oval
containingtheletterCtotheleftofnameofamedication,identifythetypeofcomplicationhere. Select
onlyone.
(M)MEDICATIONAUTHORIZATION: Thetypeoftreatmentauthorizationobtained. Selectonlyone.
PROCEDURES: Theprocedure(s)performedonthepatientbyEMS. Selectallthatapply. Certain
procedureshavefourovalstotheleftoftheprocedurename. Completetheseasfollows:
Forallproceduresperformed,fillintheovaltotheleftoftheprocedurenamecontainingthenumberofattempts,1foroneattempt,and2+formorethanoneattempt.
Ifunabletosuccessfullycompleteaprocedure,fillintheovaltotheleftoftheprocedurenamecontainingtheletterU.
Ifacomplicationisassociatedwithaprocedure,fillintheovalcontainingtheletterCtotheleftofnameoftheprocedure. Indicate,atmost,onlyoneprocedurecomplicationperrunreport. Ifthereare
complicationsassociatedwithmorethanoneprocedure,fillintheCovalonlyfortheprocedure
associatedwiththemostseriouscomplication.
Ifaprocedurehasonlyoneovaltotheleftoftheprocedurename,simplyfillinthatovaliftheprocedure
wasperformed.
PROCEDURECOMPLICATION: Ifaprocedurecomplicationwasidentifiedbyfillingintheovalcontainingthe
letterCtotheleftofnameofaprocedure,identifythetypeofcomplicationhere. Selectonlyone.
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PROCEDUREAUTHORIZATION: Thetypeofprocedureauthorizationobtained. Selectonlyone.
REASONFORCHOOSINGDESTINATION: Whythepatientwastransportedortransferredtotheselected
destination.
SpecialtyResourceCenterTransportedtoaspecialtyfacilitybaseduponuniqueneedsofthepatient,
whetherornotthiswastheclosestfacility.
PatientRequestTransportedtohospital/facilityofpatientschoice.
FamilyRequest
Transported
to
hospital/facility
chosen
by
the
patients
family
or
aperson
acting
on
the
patientsbehalf.
LawEnforcementRequestTransportedtohospital/facilitychosenbyLawEnforcement.
Patient'sPhysiciansRequestTransportedtohospital/facilitychosenbythepatientsphysician.
OnLineMedicalDirectionTransportedtohospital/facilityasdirectedbymedicalcontroleitheronlineor
onscene.
DiversionThefirstchoiceforhospital/facilitywasunabletoacceptthepatient.
ProtocolTransportedtoalternatefacilityinaccordancewithMedicalDirectorapproved
protocols/guidelines.
InsuranceStatusThehospital/facilitywaschosenbasedoninsurancecoverage.
ClosestFacility
Transported
to
the
closest
hospital/facility.
OtherNotoneoftheotheroptionslisted.
NotApplicableTherespondingunitdidnottransportthepatient.
DESTINATIONTYPE: Thetypeofdestinationtowhichthepatientwastransportedortransferred.
INCIDENT/PATIENTDISPOSITION: Thepatientstreatmentand/ortransportstatusatthetimeEMS
involvementconcluded. Thisiscriticalinformationandmustbecompletedforallcalltypes.
TransportedbyEMS ThepatientwastreatedandtransportedbythereportingEMSunit.
TransportedbyLawEnforcement Thepatientwastreatedandtransportedbyalawenforcementunit.
TransportedbyPrivateVehicle ThepatientwastreatedandtransportedbymeansotherthanEMSorlaw
enforcement.
Treated,Transferred
Care
The
patient
was
treated
but
care
was
transferred
to
another
EMS
unit.
TreatedandReleased ThepatientwastreatedbyEMSbutdidnotrequiretransporttothehospital.
PatientRefusedCareThepatientrefusedtogiveconsentorwithdrewconsentforcare.
Notreatmentrequired Assessmentofthepatientresultedinnoidentifiableconditionrequiringtreatment
byEMS.
NoPatientFound EMSwasunabletofindapatientatthescene.
DeadatSceneThepatientwaseitherdeadonarrivalordeadafterarrivalwithfieldresuscitationnot
successfulandnottransported.
CancelledTheresponsewascancelledpriortopatientcontact.
TRANSPORTMODEFROMSCENE: Theunitslightsandsirensstatusonthewayfromthescenetothe
destination.
Completefor
patient
transports/transfers
only.
PERSONALPROTECTIVEEQUIPMENTUSED: Selectallthatapply. Ifatypeofpersonalprotectiveequipment
wasusedthatisnotontheformselectOther.
DESTINATION/TRANSFERREDTO,CODE: Thefourdigitdestinationhospitalcode. Acompletelistof
destinationhospitalnamesandcodescanbeaccessedathttp://www.emsdata2.com/ILNEMSIS/. Usefor
transportsfromasceneaswellasinterfacilitytransports. Ifthetransportdestinationwasotherthana
hospitalorifthepatientwasnottransportedthisfieldshouldbeleftblank.
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DESTINATIONZIPCODE: ThefivedigitZipCodeinwhichthepatienttransportdestinationislocated. Use
fortransportsfromasceneaswellasinterfacilitytransports. Ifthetransportdestinationwasahospitalor
ifthepatientwasnottransportedthisfieldshouldbeleftblank.
EMSSystemNumber: ThefourdigitnumberidentifyingwhichtheEMSSystemunitwasoperatingunder. A
completelistofResourceHospitalsandassociatedEMSSystemnumberscanbeaccessedat
http://www.emsdata2.com/ILNEMSIS/.
TheEMS
System
number
must
be
completed
on
all
run
reports,
regardless
of
patient/incident
disposition,includingcancellationsandrefusals.
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AppendixA:IllinoisCountyCodesThestatecodeforIllinoisis17. Enterthefivedigitcombinedstateandcountycodeontheform. For
example,thecorrectentryforDuPageCounty,Illinoisis17043.
CODENAME
CODE
NAME
CODE
NAME
001 Adams 071 Henderson 141 Ogle
003 Alexander 073 Henry 143 Peoria
005 Bond 075 Iroquois 145 Perry
007 Boone 077 Jackson 147 Piatt
009 Brown 079 Jasper 149 Pike
011 Bureau 081 Jefferson 151 Pope
013 Calhoun 083 Jersey 153 Pulaski
015 Carroll 085 JoDaviess 155 Putnam
017Cass
087
Johnson
157
Randolph
019 Champaign 089 Kane 159 Richland
021 Christian 091 Kankakee 161 RockIsland
023 Clark 093 Kendall 163 St.Clair
025 Clay 095 Knox 165 Saline
027 Clinton 097 Lake 167 Sangamon
029 Coles 099 LaSalle 169 Schuyler
031 Cook 101 Lawrence 171 Scott
033 Crawford 103 Lee 173 Shelby
035
Cumberland
105
Livingston
175
Stark
037 DeKalb 107 Logan 177 Stephenson
039 DeWitt 109 McDonough 179 Tazewell
041 Douglas 111 McHenry 181 Union
043 DuPage 113 McLean 183 Vermilion
045 Edgar 115 Macon 185 Wabash
047 Edwards 117 Macoupin 187 Warren
049 Effingham 119 Madison 189 Washington
051 Fayette 121 Marion 191 Wayne
053 Ford 123 Marshall 193 White
055Franklin
125
Mason
195
Whiteside
057 Fulton 127 Massac 197 Will
059 Gallatin 129 Menard 199 Williamson
061 Greene 131 Mercer 201 Winnebago
063 Grundy 133 Monroe 203 Woodford
065 Hamilton 135 Montgomery
067 Hancock 137 Morgan
069 Hardin 139 Moultrie
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AppendixB:CodesforOutofstateCountiesBorderingIllinois
Thestatecodeisgiveninparenthesisafterthestatename. Enterthefivedigitcombinedstateandcounty
codeontheform. Forexample,thecorrectentryforLakeCounty,Indianais18089.
Indiana(18)
007 Benton
051 Gibson
083 Knox
089 Lake
111 Newton
129 Posey
153 Sullivan
165 Vermillion
167
Vigo
171 Warren
Iowa(19)
005 Allamakee
043 Clayton
045 Clinton
057 DesMoines
061 Dubuque
097
Jackson
111 Lee
115 Louisa
139 Muscatine
163 Scott
Kentucky(21)
007 Ballard
055 Crittenden
139
Livingston145 McCracken
225 Union
Missouri(29)
031 CapeGirardeau
045 Clark
099 Jefferson
111 Lewis
117 Lincoln
127 Marion
133 Mississippi
157 Perry
163
Pike
173 Ralls
183 SaintCharles
186 SainteGenevieve
189 SaintLouis
201 Scott
Wisconsin(55)
043 Grant
045
Green
059 Kenosha
065 Lafayette
105 Rock
127 Walworth
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AppendixC: EMSSystemNumbersandResourceHospitalNamesandCities
0121 St.AnthonyMedCtr,Rockford
0134 KatherineShawBethea,Dixon
0139 RockfordMemorial,Rockford
0165 KishwaukeeComm,DeKalb
0175 SwedishAmerican,Rockford
0215 TrinityMedicalCenter,RockIsland
0218 StFrancisMedicalCtr,Peoria
0219 McDonoughDistrict,Macomb
0237 BroMennRegMedCtr.,Normal
0238 St.JosephMed.Ctr.,Blm
0240
KewaneeHospital,
Kewanee
0242 St.Mary'sHosp,Galesburg
0243 GalesburgCottageHosp,Galesburg
0245 St.Mary'sHosp,Streator
0253 GenesisHospital,Silvis
0254 IllinoisValleyCommHosp,Peru
0256 OttawaRegHosp&HCCtr,Ottawa
0257 St.JamesHosp,Pontiac
0316 St.John'sHosp,Springfield
0320 BlessingHospital,Quincy
0324 PassavantHosp,Jacksonville
0327 MemorialMedCtr,Springfield
0360 JerseyCommunityHosp,Jerseyville
0425 MemorialHospital,Belleville
0432 AndersonHosp,Maryville
0451
Alton
Memorial
Hosp,
Alton
0473 St.Anthony'sHealthCtr,Alton
0476 GreenvilleRegHosp,Greenville
0526 GoodSamaritan,Mt.Vernon
0530 MemorialHospital,Carbondale
0550 MassacMemHosp,Metropolis
0562 HeartlandHospital,Marion
0564 FairfieldMemHosp,Fairfield
0623 StMary's,Decatur
0633 SaraBushLincoln,Mattoon
0644 CarleFoundation,Urbana
0663 CrawfordMemHosp,Robinson
0671 ProvenaCovenantMedCtrUrbana
0704 IngallsMemorialHosp,Harvey
0710 SilverCrossHosp,Joliet
0712 StMary'sKankakee
0729 ChristHospital,OakLawn
0746
RiversideMedical,
Kankakee
0805 LoyolaUnivMedCtr,Maywood
0828 GoodSamaritan,DownersGrove
0849 CentralDuPageHosp.Winfield
0859 EdwardHospital,Naperville
0906 CentegraNIMC,McHenry
0907 NorthwestComm,ArlingtonHts
0909 ShermanHospital,Elgin
0948 DelnorCommunity,Geneva
0961 StJoseph's,Elgin
1002 HighlandParkHosp,HighlandPark
1011 StFrancis,Evanston
1014 VistaMedCtrEast,Waukegan
1072 CondellMedlCtr,Libertyville
1103 IllinoisMasonicMedCtr,Chgo
1108
Northwestern
Memorial,
Chgo
1113 UnivofChicagoHosp,Chicago
1236 MercyHealthcare,Dubuque
1241 UnionHospital,TerreHaute
1255 St.Mary's,Evansville,IN
1275DeaconessHospital,EvansvilleIN
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AppendixD: DestinationHospitalIDs,Names,andCities**CitynotlistedforChicagohospitals. IDnumbersforallhospitalslocatedwithinChicagoscitylimitsbeginwiththenumbersix.
ID HospitalNameandCity
0578 AbrahamLincolnMemorialHosp, Lincoln
1031 AdventistBolingbrookHospital
0146
AdvocateChrist
Med
Ctr,
Oak
Lawn
0507 AdvocateCondellMedCtr, Libertyville
0508 AdvocateGoodShepherdHosp, Barrington
6058 AdvocateTrinityHosp, Chicago
0145 AlexianBrothersMedCtr, ElkGroveVillage
0653 AltonMemorialHospital
0655 AndersonHosp, Maryville
9628 BarnesJewish WestCoHospital,StLouisMO
9632 BarnesJewishHospital, StLouisMO
6004
BethanyHospital
0001 BlessingHospitalAt11ThStr,Quincy
0003 BlessingHospitalAt14Street,Quincy
0615 BromennRegionalMedCtr, Normal
9630 CardinalGlennonChildrens, StLouis MO
0083 CarleFoundationHospital,Urbana
0641 CarlinvilleAreaHospital
1003 CarmiTownshipHospital
9620 CenterPointeHosp, StCharlesMO
0236 CentralDupageHosp, Winfield
1014
CghMed
Ctr,
Sterling
6017 ChildrensMemorialHospital
9612 ChristianHospNortheast, StLouisMO
0110 ClayCountyHospital,Floria
6026 ColumbiaGrantHospital
6019 ColumbusHospital
0642 CommunityMemorialHospital,Staunton
0190 CrawfordMemorialHosp, Robinson
0416 CrossroadsCommunityHosp, MtVernon
9453
Deaconess
Hosp,
Evansville
IN
9636 DeaconessHosp, StLouisMO
9457 DeaconessGateway&Women'sHosps,
NewburghIN
0629 DecaturMemorialHospital
0460 DelnorCommunityHosp, Geneva
9624 DepaulHealthCtr, StLouisMO
9629 DesPeresHospital, StLouisMO
6030 DoctorsHospOfHydePark
ID HospitalNameandCity
0214 Dr.JohnWarnerHosp, Clinton
6022 EdgewaterHospitalAndMedicalCtr
0237 EdwardHosp,
Naperville
0238 ElmhurstMemorialHospital
1067 EurekaCommunityHospital
0992 FairfieldMemorialHospital
0275 FayetteCountyHosp, Vandalia
0860 FerrellHosp, Eldorado
9532 FinleyHosp, DubuqueIA
0299 FranklinHosp, Benton
0909 FreeportMemorialHospital
0438 GalenaStauss
Hospital,
Galena
0493 GalesburgCottageHospital
0657 GatewayRegionalMedCtr, GraniteCity
0831 GenesisMedCtrIlliniCampus, Silvis
0287 GibsonCommunityHosp, GibsonCity
0239 GlenoaksMedCtr, GlendaleHeights
0240 GoodSamaritanHosp,DownersG.
0415 GoodSamaritanRegHc, MtVern
0152 GottliebMemorialHosp, MelrosePark
0311 GrahamHosp, Canton
0025 GreenvilleRegional
Hospital
0345 HamiltonMemorialHosp, Mcleansboro
0379 HammondHenryHosp, Geneseo
0368 HardinCountyGeneralHosp, Rosiclare
0861 HarrisburgMedicalCenterInc
1041 HeartlandRegionalMedCtr, Marion
1040 HerrinHospital
0717 HillsboroAreaHospital
0153 HinesVeteransAdministrationHosp
0241 Hinsdale
Hospital6028 HolyCrossHospital
0154 HolyFamilyMedCtr, DesPlain
0944 HoopestonCommunityMemorial
0920 HopedaleHospital
0791 IlliniCommunityHosp, Pinckneyville
6032 IllinoisMasonicMedicalCenter
0527 IllinoisValleyCommunityHosp, Peru
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ID HospitalNameandCity
0002 IllinoisVeteransHome, Quincy
0156 IngallsMemorialHosp, Harvey
0392 IroquoisMemorialHosp, Watseka
6034 JacksonParkHospital&Medic
9625 JeffersonMemorialHosp, FestusMO
0427 JerseyCommunityHosp, Jerseyville
9635 JewishHospitalOfStLouis,MO
0780 John&MaryE.KirbyHosp, Monticello
6020 JohnHStrogerHosp(CookCo)
6021 JohnHStrogerHospPedTrauma
0552 KatherineShawBetheaHosp, Dixon
0848 KennethHallRegionalHosp, EastStLouis
0380 KewaneeHospital
0203 KindredHosp, Sycamore
6003
KindredHosp,
Chicago
(Central)
6068 KindredHospital(NorthCampus), Chicago
0172 KindredHospital, Northlake
6056 KindredHospitalLakeshore, Chicago
0201 KishwaukeeCommunityHosp, Dekalb
0147 LagrangeCommunityHospital,Lagrange
0510 LakeForestHospital
6035 LarabidaChildrensHosp
0541 LawrenceCoMemorialHosp, Lawrenceville
0878 LincolnPrairieBehavioralHealthCtr,
Springfield
0157 LittleCompanyOfMaryHosp, EvergreenPark
6036 LorettoHospital
6037 LouisA.WeissMemorialHospital
0150 LoyolaUniversityMedCtr, Maywood
0160 LutheranGeneralHosp, ParkRidge
0161 MacnealMemorialHosp, Berwyn
0768 MarshallBrowningHosp, DuQuoin
0683 MasonDistrictHosp, Havana
0694
Massac
Memorial
Hosp,
Metropolis
0085 McKinleyMemorialHosp, Urbana
0591 McDonoughDistrictHosp, Macomb
0403 MemorialHospitalOfCarbonda
0846 MemorialHospital, Belleville
0357 MemorialHospital, Carthage
0803 MemorialHospital, Chester
0875 MemorialMedCtr, Springfield
ID HospitalNameandCity
0603 MemorialMedCtr, Woodstock
0528 MendotaCommunityHospital
0705 MercerCountyHosp, Aledo
0602 MercyHarvardHosp
9531 MercyHealthCtr, DubuqueIA
6041 MercyHosp&MedCtr, Chicago
9510 MeriterHospital, MadisonWI
6005 MethodistHospitalOfChicago
0755 MethodistMedCtrOfIl, Peoria
0174 MetrosouthMed Ctr, BlueIsland
6042 MichaelReeseHospit
0506 MidwesternRegionalMedCtr, Zion
9639 MilwaukeeChildrensHospital,WI
9613 MissouriBaptist, ChesterfieldMO
0334 MorrisHospital
1015 MorrisonCommunityHospital
6043 Mt.SinaiHospitalMedicalCenter
7061 NonSpecIllinois
7045 NonSpecIndiana
7053 NonSpecIowa
7047 NonSpecKentucky
7052 NonSpecMinnesota(Inc.Mayo)
7063 NonSpecMissouri
7051 NonSpecWisconsin
0604 NorthernIllinoisMedCtr, McHenry
0148 NorthshoreEvanstonHospital
0151 NorthshoreGlenbrookHosp, Glenview
0509 NorthshoreHighlandParkHosp
0170 NorthshoreSkokieHospital
0162 NorthwestCommunityHosp, ArlingtonHeights
0036 NorthwestSuburbanHospital,Belvidere
6045 NorthwesternMemorialHospital
9470 NortonHosp, LouisvilleKY
6046 NorwegianAmerican
Hosp,
Inc.
0164 OakForestHospital
0165 OakParkHospital
0969 OsfHolyFamilyMedCtr, Monmouth
0757 OsfStFrancisMedCtr, Peoria
0495 OsfSt.MaryMedCtr, Galesburg
0526 OttawaRegHosp&HcCtr
6044 OurLadyOfTheResurrection
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ID HospitalNameandCity
0168 PalosCommunityHosp, PalosHeights
0098 PanaCommunityHospital,Pana
0253 ParisCommunityHospital
0732 PassavantAreaHosp, Jacksonville
0921 PekinMemorialHospital
0048 PerryMemorialHospital,Princeton
0769 PinckneyvilleCommunityHospital
0756 ProctorCommunityHosp, Peoria
0086 ProvenaCovenantMedCenter,Urbana
0466 ProvenaMercyMedCtr, Aurora
0468 ProvenaSaintJosephHosp.Elgin
1028 ProvenaStJosephMedCtr, Joliet
0482 ProvenaSt.MarysHosp, Kankakee
0945 ProvenaUnitedSamaritansMedCtr, Danville
6047
ProvidentHospital
Of
Cook
Co
6048 RavenswoodHospitalMedicalC
0807 RedBudRegionalHospital
6050 ResurrectionMedicalCenter
0818 RichlandMemorialHosp, Olney
9450 RileysChildrensHosp, IndianapolisIN
0169 RiveredgeHospital, ForestPark
0480 RiversideMedCtr, Kankakee
0743 RochelleCommunityHospital
1054 RockfordMemorialHospital
6052 RoselandCommunityHospital
0461 RushCopleyMemorialHosp, Aurora
6053 RushUniversityMedCtr, Chica
6025 SacredHeartHospital
0656 SaintAnthonysHosp, Alton
0658 SaintClaresHosp, Alton
0566 SaintJamesHosp, Pontiac
0037 SaintJosephHosp, Belvidere
0671 SalemTownshipHospital
0134
SarahBush
Lincoln
Health
Center,
Mattoon
0887 SarahD.CulbertsonMemorial, Rushville
0849 ScottAirForceMedCtr, Belleville
0898 ShelbyMemorialHosp, Shelbyville
0467 ShermanHospitalAss'N, Elgin
6057 ShrinersHospitalForCripple
1027 SilverCrossHosp, Joliet
6059 SouthShoreHospital(Luella)
ID HospitalNameandCity
0171 SouthSuburbanHosp, HazelCrest
9638 SoutheastHospital,CapeGirardeauMO
0806 SpartaCommunityHospital
9614 SsmStClare, FentonMO
0155 StAlexiusMedCtr, HoffmanEstates
1055 StAnthonyMedCtr, Rockford
9626 StAnthonys MedCtr, StLouisMO
0167 StJamesMed.Ctr. OlympiaFields
9611 StLukesHospital, ChesterfieldMO
9455 StMargaretMercy, DyerIN
9452 StMargaretMercy, HammondIN
6066 StMary&ElizabethMedCtr
9451 StMarys MedCtr, EvansvilleIN
9622 St.AlexiusHosp, StLouisMO
6061 St.Anthony
Hospital,
Chicago
0264 St.Anthonys MemHosp, Effingham
6062 St.Bernards Hosp, Chicago
6063 St.Elizabeths Hospital, Chicago
0847 St.Elizabeth's Hosp, Belleville
0173 St.FrancisHospital, Evanston
0718 St.FrancisHospital, Litchfield
0175 St.JamesHospital,ChgoHts
0876 St.Johns Hosp, Springfield
9610 St.Johns MercyMc, StLouisMO
9623 St.JosephHealthCtr, StCharlesMO
6065 St.JosephHospital, Chicago
0617 St.JosephMedCtr, Bloomington
0404 St.JosephMemorialHosp, Murphysboro
0659 St.Josephs Hosp, Highland
0122 St.Josephs Hospital,Breese
9631 St.LouisChildrensHospital,MO
9621 St.LouisUniversityHospital,MO
0049 St.Margarets Hospital,SpringValley
9633 St.Marys Hlth
Ctr,
St
Louis
MO
0672 St.Marys Hospital, Centralia
0630 St.Marys Hospital, Decatur
0530 St.Marys Hospital, Streator
0176 SuburbanHosp&Sanitarium, Hinsdale
1056 SwedishAmericanHosp, Rockford
6067 SwedishCovenantHospital
0099 TaylorvilleMemorialHosp
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ID HospitalNameandCity
0322 ThomasHBoydMemorialHosp, Carrollton
6069 ThorekHospital&MedicalCenter
0844 TouchetteRegionalHosp, Centreville
0830 TrinityMedCtrWest, RockIsland
0833 TrinityMedCtr7ThSt, Moline
0512 USArmyInfirmary,HighlandPark
0513 USNavyHospital,GreatLakes
0933 UnionCountyHospital, Anna
9454 UnionHospital, TerraHauteIN
6072 UnivOfIllinoisHospital
6071 UniversityOfChicagoMedCtr
9530 UniversityOfIowa,IowaCityIA
9634 UniversityOfMissouriClinics
0202 ValleyWestHosp, Sandwich
ID HospitalNameandCity
6073 VetAdminLakesideMedCenter
6074 VetAdminWestSideMedCtr
0947 Veterans AdminFacility, Danville
0514 VeteransAdmHospNorthChicago
1042 VetsAdminMedCtr, Marion
0511 VistaMedCtr West, Waukegan
0515 VistaMedCtrEast, Waukegan
0958 WabashGeneralHosp, MtCarmel
0981 WashingtonCountyHosp, Nashville
9456 WelbornBaptistHosp, Evansville IN
0178 WestSuburbanMedCtr, OakPark
9471 WesternBaptistHosp, PaducahKY
0179 WestlakeCommunityHosp, MelrosePark
9999 UnknownHospital
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PRIVILEGED AND CONFIDENTIAL INFORMATIONUNDER THE EMS ACT AND MEDICAL STUDIES ACT
None
No Units Available
High Call Volume
Language Barrier
Location(Inability to Obtain)
Technical Failure(Computer, Phone etc.)
Scene Safety(Not Secure for EMS)
Caller (Uncooperative)
Other
EMS Provider
PERFORMED BY
Patient
Unknown
N/A
Oth HealthcareProvider
LawEnforcement
Lay Person
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
S
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
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8
9
0
1
2
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4
5
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8
9
0
1
2
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9
0
1
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3
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9
0
1
2
3
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9
0
1
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8
9
0
1
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9
0
1
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8
9
0
1
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8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
AGENCY NO. INCIDENT NUMBERResponse
Downgrade fro
Upgrade to L
No Lights & S
INC. ONSET PSAP CALL UNIT NOTIFIED UNIT ARRIVED BACK IN SRVCLEFT SCENE ARRIVED DEST.
1
2
3
4
5
0
1
2
3
4
5
6
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8
9
0
1
2
3
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5
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7
8
9
0
1
0
2
1
2
3
4
5
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
2
1
2
3
4
5
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
2
1
2
3
4
5
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
2
1
2
3
4
5
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
2
1
2
3
4
5
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
2
:H MH M :H MH M :H MH M :H MH M :H MH M :H MH MUNIT ENROUTE AT PT.
:H MH M :H MH M :H MH M :H MH MBACK AT HOME
1
2
3
4
5
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
2
1
2
3
4
5
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
2
1
2
3
4
5
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
2
1
2
3
4
5
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
2
Allergic Reaction
Blood Glucose
Chest Pain (Non-trauma)
Cold Exposure
Altered LOC (non-trauma)
Eye Symp. (non-trauma)
Convulsions/Seizures
Non Traumatic Headache
Cardiac Symp. (atypical pain)
Heat Exposure
Hemorrhage
Infect. Diseases Requiring Isolation
Hazmat Exposure
Medical Device Failure
None
Single
Home/Residence
Street or Highway
Mine or Quarry
DO
NOTMARKINTHISAREA
2010
EMSDataSystems,Inc.
SCANNER COPY Revised 04/Illinois Department of Health
Bleeding
Breathing Problem
Change inResponsiveness
Device/EquipmentProblem
Choking
Death
Diarrhea
Drainage/Discharge
Fever
Malaise
Mass/Lesion
Mental/Psych
Nausea/Vomiting
Pain
Palpitations
Rash/Itching
Swelling
Transport Only
Weakness
Wound
SYMPTOMS (PRIMARY & OTHER)
Lights and S
Construction
PTS OCCUPATIONAL INDUSTRY
Fracture/Dislocation
Penetrating Extremity
Amputation Digits
Amputation Other
Suspected Internal Injury
MulitipleEMS NotOverwhelmed
P O
P O
P O
P O
P O
P O
P O
P O
P O
P O
P O
P O
P O
P O
None
P O
P O
P O
Abnormal
Abdominal Pain
Patient Safety
Restraints Required
Monitoring Required
Chemical Restraint
3rd Party Assistance/Attendant Reqd
P O
P O
P O
VEH. #
CPR
Extricate/Move
Manual Defib.
AED Defibrillation
Improved
Unchanged
Worse
Unknown
N/A
OUTCOME
CHIEF COMPLAINT ORGAN SYSTEM
Cardiovascular
CNS/Neuro
Endocrine/Metabolic
GI
Global
Musculoskeletal
OB/Gyn
Psych
Pulmonary
Renal
Skin
Unknown
CHIEF COMPLAINT ANATOMIC LOC
Abdomen
Back
Chest
Extremity-Lower
Extremity-Upper
General
Genitalia
Head
Neck
P O
Mark Reflex EM-277608-1:654321 GS03
HemorrhageControl/Wnd Mgmt
Airway
Abdnl/Chest Thrust
O2
Assessment
DELAYS
Scene
Transport
None
Crowd
Directions
Distance
Diversion
Extric >20
HazMat
Language
Safety
Staff
Traffic
Veh. Crash
Veh. Failure
Weather
Other
Retail Trade
Services
Transportatio& Public UtiliGovernment
Manufacturing
Mining
Finance, Insurance,& Real Estate
Wholesale Tr
Unknown
MulitipleEMSOverwhelmed
S C A N T R O N
CONDITION CODE (Select all that apply)
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
Skin Signs
Vital Signs
Insurance
Medicaid
Medicare
Not Billed(for any reason)
Unknown
PRIMARY METHODOF PAYMENT
Other Govt.
Self Pay
DISPATCH DELAY
SEVERE
Other Trauma
Monitor/Airway
Major Bleeding
Neurologic Distress
Pain (Severe)
Poisons (all routes)
Alcohol Intox./Drug OD
Severe Alcohol Intox.
Back Pain (no trauma, possible cardio/vasc)
Back Pain (no trauma, neuro sympts)
Behav/Psych (Alt. mental status)
Behav/Psych (Threat to self/others)
Special Handling
Ortho. Device Reqd
Positioning Reqd
Seclusion Required
Risk of Falling off Stretcher
Isolation
PRIOR AID
Unknown N/A
DATE
1
2
3
4
5
6
7
8
9
0
1
2
3
0
Oct
an
eb
Mar
pr
ay
un
ul
ug
ep
ov
ec
YRDAYINCIDENT COUNTY(5-digit FIPS Code)
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
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6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
INCIDENTZIP CODE
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
Prehospital
Care Report
llinois Departmentof Public Health
YEARDAY
1
2
3
4
5
6
7
8
9
0
1
2
3
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
19
20
PT DATE OF BIRTH
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
UNITS
Y
M
D
H
No
Yes, w/oPre-ArrivalInstructions
Yes, withPre-ArrivalInstructions
Female
AsianNative Hawaiian orOther Pacific Islander
American Indianor Alaska Native
White
Other Race
Unknown
Pregnant? Y
GENDER
African American/Black
Unknown
Unknown
Hispanic/Latino
Not Hispanic/Latino
Unknown
EMD PERFORMED ETHNICTY
RESP MOD
Clean-up
Decontamin
Equip. Failure
Equip. Replns
None
Other
Staff Delay
Vehicle Failu
Documentat
ED Overcrowd
WORK-RELAT
Y N
TURN-AROUND D
SERVICEREQUESTED
Intercept
MCI
Abdominal Pain
Allergies
Animal Bite
Assault
Back Pain
Breathing Problem
Burns
CO Poisoning/Hazmat
Cardiac Arrest
Chest Pain
Choking
Convulsions/Seizure
Diabetic Problem
Drowning
Electrocution
Eye Problem
Fall Victim
Headache
Heart Problems
Heat/Cold Exposure
Hemorrhage/Laceration
Ingestion/Poisoning
Pregnancy/Childbirth
Psychiatric Problem
Sick Person
Stab/Gunshot Wound
Stroke/CVA
Traffic Accident
Traumatic Injury
Unconscious/Fainting
Unk. Prob. (man down)
Industrial Accident/Inaccessible Incident/
Other Entrapments
Transfer/Interfacility/Palliative Care
InterFacilityTransfer
911 Response(Scene)
MedicalTransport
Mutual Aid
Standby
COMPLAINT REPORTED BY DISPATCH (Select one)
INCIDENT LOCATION TYPECREW MEMBER #1 ID CREW MEMBER #2 ID CREW MEMBER #3 IDPT. HOME ZIP CODEAGE
Farm
Trade or Service(Business, Bars,Restaurants, etc.)
Health CFacility(Clinic, Ho
Lake/ROcean
ResidenInstitutio(Nursing Jail/Priso
# OF PTSAT SCENE
Burns
Near Drowning
Eye Injuries
Sexual Assault Injury
Post-Op Proc. Compl.
Preg. Compl./Childbirth/Labor
Sick Person-Fever
Severe Dehydration
Unconscious/Syncope/Dizziness
Major Trauma
WorkersComp.
CMS SERVICE LEVEL
ALS, Level 1
ALS, Level 1 Emergency
ALS, Level 2
Paramed Intercept
Specialty Care Transport
Fixed Wing (Plane)
Rotary Wing (Helio)
BLS
BLS, Emerg. TBD
Male
RACE
Public Building(Schools, Gov. Offices)
Other
Place of Recreationor Sport
Industrial Place& Premises
POSSIBLEINJURY?
Y N
MAJ MIN
MAJ MIN
BLSALS
BLSALS
BLSALS
BLSALS
N/AN/A
UN
UNK
Oct
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Nov
Dec
1
2
3
4
5
6
7
8
9
0
-
8/8/2019 Instruction Manua Illinois EMS Preho Care Report Form
24/24
PROCEDURE COMPLICATION
EsophagealIntubtn-Other
PROCEDURE AUTHORIZATION
On-Line
On-Scene
Protocol (Standing Order)
Written Orders (Pt. Spec.)
Extravasion
NoneAltered MentalStatus
Esophageal Intubtn-Immediately
Apnea
Bleeding
Bradycardia
Diarrhea
REASON FOR CHOOSING DESTINATION
IV
Unknown
Other
Normal Sinus Rhythm
Agonal/Idioventricular
Artifact
Asystole
Atrial Fibrillation/Flutter
Junctional
Sinus Arrhythmia
Sinus Bradycardia
Ventricular Fibrillation
Ventricular Tachycardia
V Block
1st Degree
2nd Degree-Type 1
2nd Degree-Type 2
3rd Degree
2 Lead ECG
Anterior Ischemia
Inferior Ischemia
Lateral Ischemia
Shockable
Non-Shockable
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
PROVIDERS IMPRESSION (Primary and Secondary)
Abdominal Pain/Problems
Airway Obstruction
Allergic Reaction
Altered Level of Consc.
Behavioral/Psych Disorder
Cardiac Arrest
Cardiac Rhythm Disturbance
Chest Pain/Discomfort
Diabetic Sympt. (hypoglycemia)
Bites
Aircraft Related Acc.
Bicycle Accident
Chemical Poisoning
Child Battering
Drowning
Drug Poisoning
Electrocution
Hyperthermia
Hypothermia
Hypovolemia/Shock
Inhalation Injury (toxic gas)
Obvious Death
Poisoning/Drug Ingestion
Pregnancy/OB Delivery
Respiratory Distress
Non-Motorized Ve
Pedestrian Traffic
Radiation Exposu
Rape
Smoke Inhalation
Stabbing/Cutting
Stabbing/Cutting A
Struck by Blunt/Throw
Venom Stings (plants,
Water Transport A
Unknown
ARREST WITNESSED BY
Initiated Chest Comp.
Healthcare Provider
Lay Person
Not Witnessed
AsystoleBradycardia
Normal Sinus Rhy
PEA
Unknown AEDNon-Shockable Rh
Unknown AEDShockable Rhythm
Vent. Fibrillation
Vent. Tachycardia
Other
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
0
SYSTOLIC DIASTOLIC PULSE
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
0
PULSE OX
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
0
RESPIRATION WEIGHT
MEDICATION GIVEN & ADMINISTERED ROUTE C = Complication (if multiple complications mark only the most serious one)
None
Alt. Mental Status
Apnea
Bleeding
Bradycardia
Diarrhea
Extravasion
Hypertension
Hyperthermia
Hypotension
Hypoxia
Injury
Itching/Urtic
Nausea
Resp. Distres
Tachycardia
Vomiting
Other
P S
P S
P S
P S
P S
P S
P S
P S
P S
No
Yes, Prior to EMS Arrival
Yes, After EMS Arrival
MEDICAL HISTORY OBTAINED FROM
PresumedCardiac
CARDIAC ARREST ETIOLOGY
Resp.
Electro.
Other
1
2
3
4
5
6
7
8
9
0
SEAT ROW
POSITION OF PT.IN VEHICLE
Dash Deformity
DOA Same VehicleEjection
Fire
Rollover/Roof Deformity
Side Post Deformity
VEHICULAR INJURYINDICATORS
USE OFOCCUPANTAFETY EQUIP.
Protective Gear(Non-Clothing)
Other
None
Unknown
No AirbagPresent
1
2
3
4
5
0
Driver
P S
P S
P S
P S
P S
P S
P S
P S
P S
Respiratory Arrest
Seizure
Sex. Assault/Rape
Smoke Inhalation
Stings/Venom. Bites
Stroke/CVA
Syncope/Fainting
Traumatic Injury
Vaginal Hemorrhage
P S
P S
P S
P S
P S
P S
P S
P S
P S
Fire and Flames
Firearm Assault
Firearm (accidental)
Firearm (self-inflicted)
Lightning
Machinery Accident
Mechanical Suffocation
Non-traffic Accident
Traffic Accident
Motorcycle Accident
Motor Vehicle
Space Intrusion& > 1 ft.
Steering WheelDeformity
WindshieldSpider/Star
Middle
Right
Other
Left(non-driver)
Deployed
Front
Side
Other(Knee,Airbelt, etc.)
AIRBAGDEPLOYMENT
RESUSCITATIONATTEMPTED
Not Attempted
Considered Futile
DNR Orders
Signs of Circulation
AttemptedDefibrillation
Ventilation
FIRST MONITORRHYTHM OF TH
PATIENT
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
DESTINATION/TRANSFERRED
TO, CODE
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
DESTINATIONZIP CODE
Patient Refused C
No Treatment Req
No Patient Found
Dead at Scene
Cancelled
Eye Prtctn
Gloves
Level A Suit
Level B Suit
Level C Suit
Mask
PERSONAL PROTECTIVE EQUIPMENT USED
Released
Transferred Care
Treated
(required for non-hospitaldestinations only)
Adenosine
AlbuterolSulf.
Amiodarone
Anti-emetic
Aspirin
Atropine
Benzo. Spray
CaCl2
Dextrose25%
Dextrose50%
Diazepam
Diphenhydr.
Dopamine
Epi (1:1,000)
Epi (1:10,000)
Etomidate
Flumazenil
Furosemide
Glucagon
Hemo.agent
Lidocaine
Mag.Sulfate
Methylpred.
Metoprolol
Midazolam
Morphine Sulfate
Naloxone
Nitroglycerine
Nitrous Oxide
Other Nebulizer
Oxygen
Oxytocin
Procainamide
ANY RETURN OFSPONTANEOUS CIRCULATION
Yes, Prior to ED Arrival Only
Yes, Prior to ED Arrivaland at the ED
No
Trauma
Drowning
Premature VentricularContractions
Smell of Alcoholon Breath
Alcohol/DrugParaphernaliaat Scene
None
Language
Phys. Restrained
Unconscious
None
Impaired
Developmentally
Hearing
Physically
Speech
Unattnded/Unsuprvsd(including minors)
Premature AtrialContractions
Unknown
EMS
Law Enforcement
Private Vehicle
Transported By:
Unknown
Lap Belt
Shoulder BeltChild Restraint
Eye Protection
Helmet
PFD
ED-Unknown Rhythm
Right BundleBranch Block
Paced Rhythm
PEA
Left BundleBranch Block
No AirbagDeployed
Health Care Pers.
Pt. Admits toDrug Use
Pt. Admits toAlcohol Use
ALCOHOL/DRUGUSE INDICATORS
BARRIERS TOPATIENT CARE
Bystndr/Oth. Family Patient None
ProtectiveClothing
CARDIAC ARREST
1
2
3
0
1
2
3
0
1
0
MEDICATION COMPLICATION
INCIDENT/PATIENT DISPOSITION
TRANSPORT MODE FROM SCENE
EMSSYSTEM
lbs
kgs
SupraventricularTachycardia
Torsades De Points
Sinus Tachycardia
Airway (continued)
Respirator Operation
Suctioning
Change Trach. Tube
Combitube
CPAP
Foreign Body Removal
King LT BIAD
Needle Cricothyrotomy
Surgical Cricothyrotomy
EOA/EGTAIntubtn Confirm ETCO2
Intubation Confirm
Esophageal Bulb
Laryngeal Mask BIAD
Nasal Airway
Nasotracheal Intubation
Nebulizer Treatment
Oral Airway
Orotracheal Intubation
PEEP
Rapid Seq. Induction
Ventilator Operation
Ventilator with PEEP
Assessment
Childbirth
Contact Medical Control
CPR-Stop
Decontamination
Defib-Placement
for Monitoring
Extrication
MAST
Orthostatic BP Measure
Pain Measurement
IV
IO IM IH
ET
IV
IH
IV IO
PO IV IM
Definite
None
Possible
Contraindicationsto Thrombolytic Use
N/A
Unknown
THROMBOLYTIC
SCREEN
PO
IV ET IO
IV IO
IV
IV
IV IM
IV IM PO
IV
IV
IV
IO IMIV
IMIV
IV ET IO
IOIMIV
IMIV
IV
IV IM
IV IM IO
IV IM ET
SL
SC
SC
SC
SC
IV
IH
IV IM
IV
IV
IV IM
IV IO
IV IO
Oth PO SL
SC IM IV ET IO IH
= Endotracheal
= Inhalation
= Intramuscular
= Intranasal
ROUTE
ET
IH
IM
IN
Negative
Positive
Non-conclusive
Cincinnati
STROKE SCALE
Scale
Assessment
5
4
3
2
1
EYES
VERBAL(5yrs)
Spont.(