Use the information below to put into your standard policy ... … · Web viewStaff/Volunteer...

Use the information below to put into your standard policy format. Included is purpose, policy, procedure, references (use what you need to fit your facility’s format). Make sure it includes notations that show when you implemented it and that you review/revise it at least annually (this can be in the header, or at the end of the document.

Subject: Emergency Tracking System

Purpose: To provide a system to track the location of on-duty staff and sheltered patients in the ASC’s care during an emergency.

Policy: The ASC will maintain a system to track the location of on-duty staff and patients during an emergency /disaster incident including relocation information. This includes staff, physicians, contracted individuals, and volunteers.

Procedure:

1. The ASC has a process in place to know on any given day what staff are working. You will need to explain how this is done for your specific facility. Examples may be by written/electronic schedule, time records as employee checks in/out of office, etc.)

2. The ASC has a process in place to know at any given time what patients are in the facility and their location e.g., waiting room, pre-op, procedure/surgery, post-op.

3. At the onset of an announced emergency/disaster, the Incident Commander will require staff to confirm the accuracy of its staff and patient roster.

4. At the onset of an announced emergency/disaster, the Incident Commander will require of staff to log and determine the whereabouts of any visitors in the facility. This includes visitors that are associated with the patient and visitors associated with the business.

5. The logs will include the name of the individual and the area where the individual is located/assigned. A separate log will be maintained for staff/business visitors and patients/affiliated visitors. Multiple logs may be necessary depending on open departments at the time of the incident and during the course of the incident. (See attached Staff log and Scheduled Patient log).

6. Staff / business visitors:

a. If additional staff / visitors enter the ASC during the disaster (either as a matter of course or as called in) their information will be added to the appropriate log.

b. If staff are re-assigned to different areas or visitors are moved to safe areas, the time and location will be noted on the log.

c. As staff / visitors leave the ASC, as relieved of duty or finished business, the time of departure will be noted on the log.

d. If the event that the ASC is evacuated, the time and specific relocation information will be added to the log.

e. If the ASC closes, the requirement of tracking staff is no longer applicable.

7. Patients / affiliated visitors:

a. If additional scheduled patients and their affiliated visitors enter the ASC during the course of an incident, their information will be added to the appropriate log.

b. As patients move through the procedure process and/or are moved to safe areas, the time and location will be noted on the log.

c. Visitors may be asked to remain with their affiliated patient and/or moved to a safe area in the ASC at the discretion of the Incident Commander and/or based on the situation.

d. If patients are discharged during the incident, the time and discharge location will be noted on the log. Their affiliated visitor information will be updated.

e. If patients are transferred to another healthcare provider location, the time and disposition will be noted on the log. Their affiliated visitor information will be updated.

f. If the ASC is evacuated, the location of the staging area will be noted on the log until final discharge/disposition is noted.

g. The ASC is not required to track the location of patients who have voluntarily left on their own, or have been appropriately discharged, since they are no longer in the ASC’s care. However, this information must be documented in the patient’s medical record.

h. If the ASC is able to cancel surgeries and close, the requirement of tracking patients would no longer be applicable.

8. Logs will periodically be copied and provided to the Incident Commander during the course of the incident.

9. The location and movement of patients can be noted on a geographic tracking board in each location within the ASC as well as in the command center.

10. Non-scheduled arrival of individuals seeking treatment at the ASC will be tracked using a disaster triage method and information will be maintained on a log. Tracking information will include the current location of the patient and final disposition. (See attached Disaster Patient Tracking log.) (Options for charting of patient care may be SMART Triage tags or a Disaster Medical Record. Once you have determined which of these your facility will use, that should be documented here and the SMART Triage Tag or Disaster Medical Record referenced as attached.)Both have been added at the end of this document for your reference and you should delete the one not using. Or add a different form if you chose not to use either of these.

11. The Incident Commander will ensure that all logs are maintained for documentation purposes.

12. The incident Commander will make information known to local jurisdiction have authority and/or appropriate private/public agencies regarding the staff/patients/visitors regarding the location and/or specific relocation as deemed appropriate. (See Communication Plan.)

Staff/Business Visitor Tracking Log – To be used for staff, physicians, contractors, volunteers, visitors for business purposes

(An alternate may be to use HICS form 252 – Section Personnel Time Sheet and 253 – Volunteer Registration)


Time Log initiated _______Time(s) Log submitted to Command Center ____________ Time(s) Log updated ________________

Name of Individual

Indicate Staff Title, Physician, Contracted Agency, Volunteer, or Business reason for being at ASC

Initial Time and Location

Change to Location and affiliated time



Final disposition and time

Staff/Volunteer Tracking form.

Alternatives may be to use HICS forms 252 – Section Personnel Time Sheet and HICS form 253 – Volunteer Registration (attached)


Patient Name

Time and Location of patient

Change of location and affiliated time



Final Disposition of Patient, e.g., discharged or transferred, specify name of receiving facility and/or location

Visitor Name(s)affiliated with patient

Visitor location and changes to location

Scheduled Patient/Visitor Tracking Log – To be used for tracking scheduled patients and their affiliated visitors

An alternate may be to use HICS for 255 – Master patient evacuation tracking and/or HICS 260 – Patient Evacuation Tracking Form (attached)

Name

Sex

DOB/Age

Triage Category

Immediate

Delayed

Minor

Expectant

Expired

Location/Time of Procedures

Imaging, Sutures, Casting, Etc.

Disposition/Time

Discharge Location

Transfer Location

Disaster Patient/Visitor Tracking Log – To be used for tracking disaster patients and their affiliated visitors

An alternate may be to use HICS form 254 – Disaster Victim / Patient Tracking (attached)

HICS 252 - SECTION PERSONNEL TIME SHEET

1. Incident Name

2. Operational Period (# )

DATE: FROM: _____TO: _____ TIME:FROM: _____TO: _____

3. Time Record

#

EMPLOYEE (E) VOLUNTEER (V)

NAME (PRINT)

E / V

EMPLOYEE NUMBER

RESPONSE FUNCTION SECTION / ASSIGNMENT

DATE / TIME IN

DATE / TIME OUT

TOTAL HOURS

SIGNATURE

(TO VERIFY TIMES)

1

2

3

4

5

6

7

8

9

10

4. Prepared by

PRINT NAME: SIGNATURE: _______________________________________________________________________

DATE/TIME: _______________________________________________________________________FACILITY: __________________________________________________________________________

Purpose: Record each section’s personnel time and activities

CA EMSA

D:20140219175133-08'00'2/19/2014 5:51:33 PM

-------------------------------------------- To insert team logo:

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2. right click image and copy

3. paste to PDF from menu bar or Ctrl+V

4. resize logo and move to this box

Origination: Hospital Incident Management Team (HIMT) personnel as directed by Incident Commander or Section Chief

Copies to: Time Unit Leader

HICS 252 | Page 1 of 1

HICS 252 - SECTION PERSONNEL TIME SHEET

PURPOSE: The HICS 252 - Personnel Time Sheet is used to record each section’s personnel time and activities.

ORIGINATION: Section Chiefs are responsible for ensuring that personnel complete the form.

COPIES TO: Provided to the Finance/Administration Section Time Unit Leader every 12 hours

or every operational period (as directed by the Incident Commander). A copy is given to the

Documentation Unit Leader.

NOTES: If additional pages are needed, use a blank HICS 252 and repaginate as needed.

Additions may be made to the form to meet the organization’s needs.

NUMBER

TITLE

INSTRUCTIONS

1

Incident Name

Enter the name assigned to the incident.

2

Operational Period

Enter the start date (m/d/y) and time (24-hour clock) and end date and time for the operational period to which the form applies.

3

Time Record

Employee (E) / Volunteer (V) Name (Print)

Print the full name of the personnel assigned.

E / V

Enter employee (E) or volunteer (V).

Employee Number

If employee of the organization, fill in employee number.

Response Function Section / Assignment

Enter assignment being assumed.

Date / Time In

Enter time started in assignment.

Date / Time Out

Enter time ended in assignment.

Total Hours

Enter total number of hours in assignment.

Signature

Employee/volunteer signature verifying that times are correct.

4

Prepared by

Enter the name and signature of the person preparing the form. Enter date (m/d/y), time prepared (24-hour clock), and facility.

HICS 2014

HICS 253 - VOLUNTEER REGISTRATION

1. Incident Name


DATE:FROM: TO: _ TIME: FROM: TO:

3. Registration Information

NAME

(LAST NAME, FIRST NAME)

CERTIFICATION / LICENSE AND NUMBER

ID NUMBER (DRIVERS LICENSE OR SSN)

ADDRESS

(CITY, STATE, ZIP)

CONTACT INFO

(PHONE, CELL)

BADGE ISSUED

BADGE RETURNED

TIME IN / OUT

SIGNATURE

4. Prepared by PRINT NAME: ____________________________________________________________________ SIGNATURE: ____________________________________________________________________________

DATE/TIME ______________________________________________________________________ FACILITY: _______________________________________________________________________________

Purpose:To document volunteer information for each operational period

CA EMSA

D:20140219181940-08'00'2/19/2014 6:19:40 PM






Origination: Labor Pool and Credentialing Unit Leader

Copies to:Time Unit Leader, Personnel Tracking Manager, and Documentation Unit Leader


HICS 253 - VOLUNTEER REGISTRATION

PURPOSE: The HICS 253 -Volunteer Registration is used to document volunteer sign in and sign out for each Operational Period.

ORIGINATION: Completed by the Logistics Section Labor Pool and Credentialing Unit Leader.

COPIES TO: Copies are distributed to the Time Unit Leader, Personnel Tracking Manager, and


NOTES: If additional pages are needed, use a blank HICS 253 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.

NUMBER

TITLE

INSTRUCTIONS

1

Incident Name


2

Operational Period


3

Registration Information

Name

Enter the full name of volunteer.

Certification / License and

Number

If volunteer holds a certification or license, enter type and number.

ID Number

Enter a Driver’s License number or Social Security Number.

Address

Enter address.

Contact Info

Enter phone number.

Badge Issued

Enter yes or no, and number if used.

Badge Returned

Enter yes or no.

Time In / Out

Time (24-hour clock) volunteer was in and out.

Signature

Signature of volunteer verifying that information is correct.

4

Prepared by


HICS 2014

HICS 255 - MASTER PATIENT EVACUATION TRACKING

1. Incident Name

2. Operational Period (#)

DATE:FROM: TO: TIME: FROM: TO:

3. Patient Evacuation Information

PATIENT NAME

Medical Record #

Evacuation Triage Category

IMMEDIATE DELAYED MINOR

Mode of Transport

CCT ALS BLS VAN

BUS CAR AIRCRAFT

Disposition

DISCHARGE

TRANSFER

MORGUE

Accepting Hospital or Location

Time hospital contacted & report given

Transfer Initiated (Time/Transport Co./ #)

Medical Record Sent

YES NO

Medication Sent

YES NO

Family Notified

YES NO

Arrival Confirmed

YES NO

Admit Location

FLOOR ICU

ER MORGUE

Expired (time)

PATIENT NAME

Medical Record #



Mode of Transport

CCT ALS BLS VAN

BUS CAR AIRCRAFT

Disposition

DISCHARGE

TRANSFER

MORGUE




Medical Record Sent

YES NO

Medication Sent

YES NO

Family Notified

YES NO

Arrival Confirmed

YES NO

Admit Location

FLOOR ICU

ER MORGUE

Expired (time)

PATIENT NAME

Medical Record #



Mode of Transport

CCT ALS BLS VAN

BUS CAR AIRCRAFT

Disposition

DISCHARGE

TRANSFER

MORGUE




Medical Record Sent

YES NO

Medication Sent

YES NO

Family Notified

YES NO

Arrival Confirmed

YES NO

Admit Location

FLOOR ICU

ER MORGUE

Expired (time)

PATIENT NAME

Medical Record #



Mode of Transport

CCT ALS BLS VAN

BUS CAR AIRCRAFT

Disposition

DISCHARGE

TRANSFER

MORGUE




Medical Record Sent

YES NO

Medication Sent

YES NO

Family Notified

YES NO

Arrival Confirmed

YES NO

Admit Location

FLOOR ICU

ER MORGUE

Expired (time)

4. Prepared byPRINT NAME: SIGNATURE: DATE/TIME: FACILITY:

Purpose:Record information concerning patient disposition during an evacuation

CA EMSA

D:20140220132558-08'00'2/20/2014 1:25:58 PM






Origination: Situation Unit Leader or designee (Patient Tracking Manager)

Copies to:Planning Section Chief, Documentation Unit Leader

.


HICS 255 - MASTER PATIENT EVACUATION TRACKING

PURPOSE: The HICS 255 - Master Patient Evacuation Tracking form records the disposition of patients during a facility evacuation.

ORIGINATION: Completed by Planning Section Situation Unit Leader or designee (Patient Tracking Manager).

COPIES TO: Distributed to the Planning Section Chief and the Documentation Unit Leader.

NOTES: The form may be completed with information taken from each HICS 260 - Patient Evacuation Tracking form. If additional pages are needed, use a blank HICS 255 and repaginate as needed.

NUMBER

TITLE

INSTRUCTIONS

1

Incident Name


2

Operational Period


3

Patient Evacuation Information

Patient Name

Enter the full name of the patient.

Medical Record #

Enter medical record number.


Indicate the categories as defined by the facility (not necessarily the same as emergency department admitting triage system).

Mode of Transport

Indicate the mode of transport or write in if not indicated.

Disposition

Indicate the patient’s disposition.


Enter the accepting hospital or location (e.g., Alternate

Care Site, holding site).

Time hospital contacted &

report given

Enter time prepared (24-hour clock).

Transfer Initiated

Enter time, vehicle company, and identification number.

Medical Record Sent

Indicate yes or no.

Medication Sent

Indicate yes or no.

Family Notified

Indicate yes or no.

Arrival Confirmed

Indicate yes or no.

Admit Location

Indicate the applicable site.

Expired

Enter time (24-hour clock) of deceased if necessary.

4

Prepared by


HICS 2014

1. Date

2. From (Unit)

3. Patient Name

4. DOB

5. Medical Record Number

6. Diagnosis

7. Admitting Physician

8. Family Notified YESNO NAME: CONTACT INFORMATION: _

9. Mode of Transport

10. Accompanying Equipment (check those that apply)

Hospital Bed Gurney Wheelchair Ambulatory Other:

IV Pump(s) Oxygen Ventilator Chest Tube(s) Other:

Isolette/Warmer

Traction

Monitor

A-Line/Swan

Other:

Foley Catheter Halo-Device Cranial Bolt/Screw

Intraosseous Device

Other:

11. Special Needs

12. IsolationYESNOTYPE: REASON:

13. Evacuating Clinical Location

14. Arriving Location

ROOM #TIME

ROOM #TIME

ID BAND CONFIRMED BY:

YESNO

ID BAND CONFIRMED BY:

YESNO

MEDICAL RECORD SENT

YESNO

MEDICAL RECORD RECEIVED

YESNO

BELONGINGS

WITH PATIENT

LEFT IN ROOM NONE

BELONGINGS RECEIVED

YESNO

VALUABLES

WITH PATIENT

LEFT IN SAFE NONE

VALUABLES RECEIVED

YESNO

MEDICATIONS

WITH PATIENT

LEFT ON UNIT PHARMACY

MEDICATIONS RECEIVED

YESNO

PEDS / INFANTS

PEDS / INFANTS

BAG/MASK WITH TUBING SENT

YESNO

BAG/MASK /W TUBING RCVD

YESNO

BULB SYRINGE SENT

YESNO

BULB SYRINGE RECEIVED

YESNO

15. Transferring to another Facility / Location

TIME TO STAGING AREATIME DEPARTING TO RECEIVING FACILITY

Destination

TRANSPORTATIONAMBULANCE. #AGENCYHELICOPTEROTHER

ID BAND CONFIRMEDYESNOBY

DEPARTURE TIME:

16. Prepared by

PRINT NAME: SIGNATURE: _

DATE/TIME: ________FACILITY:

HICS 260 - PATIENT EVACUATION TRACKING FORM

Purpose:Detail and account for patients transferred to another facility Origination: Inpatient/Outpatient Unit Leader or Casualty Care Unit Leader Copies to: Patient Tracking Manager, Medical Care Branch Director,

evacuating clinical location, and Documentation Unit Leader

HICS 260 I Page 1 of 1

PURPOSE: The HICS 260 - Patient Evacuation Tracking Form documents details and account for patients transferred to another facility.

ORIGINATION: Completed by the Operations Section as appropriate: the Inpatient Unit Leader, the Outpatient Unit Leader, or the Casualty Care Unit Leader, depending on where the identified patient is located.

COPIES TO: The original is kept with the patient through actual evacuation. Copies are distributed to the Patient Tracking Manager, the Medical Care Branch Director, the evacuating clinical location, and the Documentation Unit Leader.

NOTES: The information on this form may be used to complete HICS 255, Master Patient Evacuation Tracking Form. Additions or deletions may be made to the form to meet the organization’s needs.

NUMBER

TITLE

INSTRUCTIONS

1

Date

Enter the date of the evacuation.

2

From

Enter the Unit the patient is leaving from.

3

Patient Name

Enter the patient’s full name.

4

DOB

Enter the patient’s date of birth (DOB).

5

Medical Record

Number

Enter the patient’s medical record number.

6

Diagnosis

Enter the primary diagnosis/diagnoses.

7

Admitting Physician

Enter the name of the patient’s admitting physician.

8

Family Notified

Check yes or no; enter family contact information.

9

Mode of Transport

Identify mode of transportation needed.

10

Accompanying

Equipment

Check appropriate boxes for any equipment being transferred with the patient.

11

Special Needs

Indicate if the patient has special needs, assistance, or requirements.

12

Isolation

Indicate if isolation is required, the type, and the reason.

13

Evacuating Clinical

Location

Fill in information and check boxes to indicate originating room and what was sent with the patient (records, medications, and belongings).

14

Arriving Location

Fill in information and check boxes to indicate patient’s arrival at the new location and whether materials sent with the patient were received.

15

Transferring to another Facility / Location

Document arrival and departure from the staging area, confirmation of ID band, and type of transportation used.

16

Prepared by


HICS 2014

HICS 254 – DISASTER VICTIM / PATIENT TRACKING

1. Incident Name


DATE: FROM: TO: TIME:FROM: _TO:

3. Area (Triage or Specific Treatment Area)

FIELD TAG NUMBER

MEDICAL RECORD NUMBER

NAME

(LAST NAME, FIRST NAME)

SEX

(M/F)

DOB / AGE

TRIAGE CATEGORY


EXPECTANT

EXPIRED

LOCATION / TIME OF PROCEDURES

(CT, X-RAY, ETC.)

DISPOSITION / TIME (D) DISCHARGE (A) ADMIT

(S) SURGERY (T) TRANSFER (M) MORGUE

4. Prepared by

PRINT NAME: SIGNATURE:

DATE/TIME: FACILITY: _

Purpose:Records the triage, treatment, and location of victims/patients

CA EMSA

D:20140220094645-08'00'2/20/2014 9:46:45 AM






Origination: Patient Tracking Manager or team

Copies to:Situation Unit Leader, Patient Registration Unit Leader, Planning Section Patient Tracking Manager, Medical Care Branch Director, and Documentation Unit Leader


HICS 254 - DISASTER VICTIM / PATIENT TRACKING

PURPOSE: The HICS 254 Disaster Victim / Patient Tracking records the triage, treatment, and disposition of victims/patients of the event seeking medical attention.

ORIGINATION: Completed by the Patient Tracking Manager or team members.

COPIES TO: Distributed to the Situation Unit Leader, with copies to Patient Registration

Unit Leader, Planning Section Patient Tracking Manager, Medical Care Branch Director, and the


NOTES: The form is completed upon arrival of the first patient and updated periodically. Copies of the form are sent to the Planning Section Patient Tracking Manager each hour and at the end of each operational period until disposition of the last victim(s) are known. If additional pages are needed, use a blank HICS 254 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.

NUMBER

TITLE

INSTRUCTIONS

1

Incident Name


2

Operational Period


3

Area

Enter the triage or specific treatment area (e.g., Triage, Immediate Treatment Area).

Field Tag Number

Enter field triage tag number.

Medical Record Number

Enter hospital medical record number if available.

Name

Enter the full name of victim/patient.

Sex

Enter sex: M for male/F for female.

DOB / Age

Enter date of birth and age.

Triage Category

Enter the triage category assigned to patient.

Location / Time of Procedures

Enter location destination and time patient leaves triage or treatment area for a test or procedure.

Disposition / Time

Enter the letter of the disposition category and time of disposition.

4

Prepared by

Enter the name and signature of the person

preparing the form. Enter date (m/d/y), time prepared

(24-hour clock), and facility.

HICS 2014

SMART Triage Tag System

http://www.smartmci.com/products/triage/smart_triage_pac.php

Example of a Disaster Medical Record

Use the information below to put into your standard policy ... … · Web viewStaff/Volunteer...

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