Aegis Field Pro

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Crew

Unit

EMS Agency Name

EMS Agency Number

Vehicle (Unit) No.

EMS Unit Callsign

Primary Role of the Unit

Level Of Care Provided Per Protocol

Dispositions

Unit Disposition

Patient Evaluation/Care

Crew Disposition

Transport Disposition

Incident and Dispatch

Patient Care Report Number

Incident Number

Incident Date

Arrival Time

Cross Street

Street Address

Apartment, Suite, or Room

City/Town

State

Zip Code

County

Facility or Location Name

Incident Location Type

Type of Service Requested

Dispatch Reason

Response Mode to Scene

Additional Mode Descriptors

First EMS Unit On Scene

Other EMS or Public Safety Agencies on Scene

Patient Information and History

First Name

Middle Initial/Name

Last Name

Date of Birth

Age

Gender

Race

Estimated Body Weight (lbs)

Estimated Body Weight (kg)

Patient's Home Address

Patient's Apartment, Suite or Room

Home City

Patient's Home State

Medication Allergies

Environmental/Food Allergies

Current Medications

Medical/Surgical History

Other Past Medical History

Chief Complaint / Provider Impression

Complaint Type	Complaint as Described by Patient:	Duration of Complaint

Chief Complaint Anatomical Location

Chief Complaint Organ System

Initial Patient Acuity

Provider's Primary Impression

Primary Symptom

Provider's Secondary Impressions

Other Associated Symptoms

Barriers to Patient Care

Vital Signs

Assessment

Head-to-Toe Assessment

Pain Scale & PQRST

Pain Scale Score

Provoked

Quality

Region

Radiation

Duration

PQRST Narrative

Procedures

Medications

Trauma Detail

Possible Injury

Cause of Injury

Mechanism of Injury

Trauma Triage Criteria (High Risk for Serious Injury)

Trauma Triage Criteria (Moderate Risk for Serious Injury)

Use of Occupant Safety Equipment

Airbag Deployment

Cardiac Arrest (Unfinished)

Cardiac Arrest

Cardiac Arrest Etiology

Resuscitation Attempted by EMS

Arrest Witnessed By

AED Use Prior To EMS Arrival

Type of CPR Provided

First Monitored Arrest Rhythm of the Patient

Narrative

Transport

Destination/Transferred To

How Patient Was Moved To Ambulance

Position of Patient During Transport

How Patient Was Moved From Ambulance

EMS Transport Method

Transport Mode From Scene

Additional Transport Mode Descriptors

Final Patient Acuity

Signatures

PATIENT CARE REPORT

Incident

Incident Number

Arrival Time

Unit Disposition

Patient Evaluation/Care

Crew Disposition

Transport Disposition

Resource

Agency Name

Agency Number

Callsign

Unit

Primary Role

Level of Care

Crew Members

Dispatch

Service Requested

Complaint Reported

Incident Location

Cross Street

Street Address

Apt / Ste

City/Town

County

State

Country

United States

ZIP Code

Location Name

Response

Response Mode

Descriptors

Scene

First EMS on Scene

Other Agencies On Scene

Location Type

Possible Injury

Vital Signs

Time	AVPU	BP	HR	ECG	SpO₂	RR	GCS	BGL	Temp	ETCO2

Incident Date	Incident #	Arrival Time	Unit / Callsign
Location

Type of Service	Dispatch Reason	Incident Location Type	Response Mode
Response Mode Descriptors

Patient Name	DOB	Age	Gender
Home Address		Estimated Weight

Chief Complaint(s)	Provider Impression
Primary Symptom / Other Symptoms	Barriers to Care

Allergies	Current Medications
Medical/Surgical History
Other Past Medical History

Crew

Name	ID	Level	Role(s)

Dispositions

Unit

Patient Eval/Care

Crew

Transport

Other Agencies on Scene

Agency	Unit/Badge	Type	First Agency Providing Care?

PREHOSPITAL PATIENT CARE REPORT

PCR #

Vitals

Time	BP	HR	RR	SpO₂	Temp	GCS	BGL	Notes

Medications Administered

Time	Medication	Dose	Route	Crew	Comments

Procedures

Time	Procedure	Size	Attempts	Crew	Comments

Narrative

Pain / PQRST Narrative

Signatures