Incident

Incident Number

Patient Care Report Number

Incident Date

Incident Time

Unit

Agency Name

Agency Number

Unit

Call Sign

Primary Role

Level of Care Provided

Crew Members

Dispatch

Service Requested

Complaint Reported

Dispatch Center

Response

Response Mode to Scene

Additional Mode Descriptors

Incident Location

Facility/Location Name

Cross Street

Street Address

Apartment, Suite, or Room

City

County

State

ZIP Code

Dispositions

Unit Disposition

Patient Evaluation/Care

Crew Disposition

Transport Disposition

Reason for Refusal/Release

Impediments

Response Impediments

Scene Impediments

Transport Impediments

Type of Turn-Around Delay

PCR Transfer

Received From Agency

Received from Agency ID

Received from Call Sign

Scene

First EMS Unit On Scene

Other EMS or Public Safety Agencies on Scene

Incident Location Type

Possible Injury

Work-Related Illness/Injury

Identification

First Name

Middle Initial/Name

Last Name

Date of Birth

Age

Gender

Race

Estimated Body Weight (lbs)

Estimated Body Weight (kg)

SSN

Patient's Home Address

Patient's Apartment, Suite or Room

Patient's Home City

Patient's Home State

Patient's Home County

History

Medical/Surgical History

Other History

History Obtained From

Allergies & Medications

Medication Allergies

Environmental/Food Allergies

Current Medications

Barriers to Care

Alcohol/Drug Use

Chief Complaint / Provider Impression

Complaint Type	Complaint as Described by Patient:	Duration

Chief Complaint Location

Chief Complaint System

Primary Symptom

Symptom Began/Discovered Date

Symptom Began/Discovered Time

The date and time the symptom began (or was discovered) as it relates to this EMS event. This is described or estimated by the patient, family, and/or healthcare professionals.

Last Known Well Date

Last Known Well Time

The estimated date and time the patient was last known to be well or in their usual state of health. This is described or estimated by the patient, family and/or bystanders.

For stroke related events, this is the date and time the patient was last seen normal.

For cardiac or respiratory arrest related events, this is the date and time the patient was last known to have a pulse or when interaction was had with the patient.

For drowning related events, this is the date and time the patient was last seen.

For injury and trauma related events, this is the date and time the patient was injured.

Last Known Well Time is ALWAYS BEFORE Symptom Began/Discovered

Other Associated Symptoms

Patient Activity

Provider's Primary Impression

Provider's Secondary Impressions

Vital Signs

Invasive Airway

Indications for Invasive Airway

Invasive Airway Confirmations

Airway Complications

Suspected Reasons for Failed Attempts

Assessment

Cardiac Arrest

Initial Patient Acuity

Physical Exams

Exam Findings

Procedures

Medications

Mechanism

Cause of Injury

Mechanism of Injury

Trauma Center Criteria

Injury Risk Factor

Safety Equipment Used

Airbag Deployment

Work Related

Industry

Occupation

Cardiac Arrest

Time of Arrest

Cardiac Arrest Etiology

Witnessed By

Who Provided CPR Prior

AED Prior To EMS Arrival

Who Provided AED Prior

First Monitored Arrest Rhythm of the Patient

Provided By EMS

Type of CPR Provided

Return of Spontaneous Circulation

Time Discontinued / Not Initiated

Reason Discontinued / Not Initiated

Rhythm on Transfer of Care

End of EMS Arrest Event

Death Pronounced By:

Stroke

mLAPSS Criteria

Age over 17 years?

No prior history of seizures

LKWT within 24 hours?

Patient ambulatory at baseline prior to event?

Blood glucose between 60-400?

LAMS Stroke Score

Stroke Scale Facial Droop

Stroke Scale Arm Drift

Stroke Scale Grip Strength

Stroke Scale Total Score

Destination

Receiving Facility

Reason For Destination

Destination Address

Disposition

Moved Patient to Ambulance by

Position During Transport

Moved Patient From from Ambulance by

Transport Method

Transport Mode

Transport Mode Descriptors

Final Patient Acuity

Belongings

Patient Belongings

Belongings Description

Patient Belongings Left With

Belongings Belongings Left With Description

Narrative

Signatures

Credits

Made with ❤️ by Ella.

Special thanks to Trevor for inspiration and providing much needed reference material!

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This was created for private use only between friends.

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References:
- NEMSIS 3.5
- Los Angeles County LAC-EMS
- Orange County OC-MEDS
- Riverside County REMSIS
- AMR Inland Empire Training
- San Diego County LEMSIS
- Maryland MIEMSS
- New York NYS-BEMS

PS: "You're not supposed to use 3rd-party software because policy says-" you can kindly fuck off x

PATIENT CARE REPORT

Incident

Incident Number

Report Number

Incident Date

Incident Time

Unit Disposition

Patient Evaluation/Care

Crew Disposition

Transport Disposition

Resource

Agency Name

Agency Number

Call Sign

Unit

Primary Role

Level of Care

Crew Members

Impediments

Response

Scene

Transport

Turn-Around

PCR Transfer

Received From

From Call Sign

Dispatch

Service Requested

Complaint Reported

Dispatch Center

Incident Location

Cross Street

Street Address

Apt / Ste

City

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

Work-Related

Mechanism

Cause of Injury

Mechanism of Injury

Trauma Criteria

Injury Risk Factor

Safety Equipment

Airbag Deployment

Work Related

Work Industry

Work Occupation

Identification

First Name

Last Name

DOB

SSN

Home Address

Apt / Ste

City

County

State

Country

United States

Description

Age

Race

Gender

Weight (kg)

Assessment

Cardiac Arrest

Initial Acuity

Assessment

Vital Signs

Time	AVPU	BP	HR	ECG	SPO2	RR	GCS	BGL	T °C	ETCO2	Assessed By

GCS

Time	Eye Opening	Verbal Response	Motor Response	Qualifier	GCS	Assessed By

PQRST

Time	Pain	Provoked	Quality	Radiation	Region	Duration	Assessed By

Barriers to Care

Alcohol/Drug Use

Complaint

Complaints

Chief Location

Chief System

Primary Symptom

Symptoms Began

Last Known Well

Other Symptoms

Patient Activity

Primary Impression

Secon. Impressions

History

Other History

Obtained From

Medications & Allergies

Current Medication

Medication Allergies

Environmental/Food Allergies

Stroke

mLAPSS Criteria

Age Over 17

No Seizure History

LKWT < 24 Hours

Ambulatory Prior

BGL 60-400

LAMS Stroke Score

Facial Droop

Arm Drift

Grip Strength

Total LAMS Score

Cardiac Arrest

Time of Arrest

Resus. Attempted

Arrest Witness

Etiology

Who Started CPR

AED Before Arrival

Who first defib.

Type of CPR

First Known Arrest Rhythm

Any ROSC

Rhythm at Dest

Time Resuscitation Stopped

Reason for Stopping

End of Event

Death Pronounced By

Actions

Procedures Performed

Time	Crew	Role of Crew	Procedure	Size	Attempts	Comments

Medications Given

Time	Crew	Role of Crew	Medication	Route	Dose	Unit	Comments

Invasive Airway

Indications

Airway Confirmations

Time	Crew	Role of Crew	Airway	Method	Depth

Complications

Failed Reasons

Disposition

Method

Transport Mode

Descriptors

To Ambulance By

Transport Position

From Ambulance By

Refusal/Release

Final Acuity

Destination

Receiving Facility

Destination Reason

Address

Belongings

Left With

Items Description

Who Description

Narrative

Signatures