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ETD Pre Hospital Care and Ambulance (PHC)

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ASSIGN CALL CARD

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Call Card No

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Date Call Received

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Event Code

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Priority

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Complaint

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Incident Location

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Landmark

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Location Type

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Distance to Scene

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Caller Contact No

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AMBULANCE INFORMATION

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Response Team

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Dispatch Time

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Enroute

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At Scene

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At Patient

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Transporting

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At Hospital

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Reroute

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Mission Abort

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RESPONSE TEAM

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SCENE ASSESSMENT

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PPE

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Others

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Environment

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Case Type

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Patient

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Backup

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Other Services Already at Scene

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Others

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PATIENT INFORMATION

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PATIENT ASSESSMENT

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Appearance

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Level of Responsiveness

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Airway Patency

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Respiratory Effort

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Air Entry

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Right Lung

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Left Lung

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Breath Sound

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Right Lung

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Left Lung

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Heart Sound

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Skin Assessment

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Ecg

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Abdomen Palpation

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Abdomen Abnormality Location

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Stroke Scale (If applicable)

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Balance

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Face

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Eye Sight

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Speech

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Arm

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TRAUMA ASSESSMENT

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Head

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Face

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Neck

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Neck Abnormality Location

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Back

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Back Abnormality Location

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Spine

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Spine Abnormality Location

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Right Chest

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Left Chest

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Abdomen

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Right Upper Quadrant

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Left Upper Quadrant

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Right Lower Quadrant

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Left Lower Quadrant

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Limb

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Right Arm

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Left Arm

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Right elbow

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Left elbow

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Right Forearm

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Left Forearm

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Right wrist

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Left wrist

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Right Hand

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Left Hand

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Pelvic

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Right hip

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Left hip

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Right Femur

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Left Femur

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Right Leg

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Left Leg

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Right knee

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Left knee

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Right ankle

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Left ankle

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Right Feet

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Left Feet

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INTERVENTION

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Airway Device Intervention

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Oxygen

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External Haemorrhage Control Method

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Vascular Access

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Vascular Access Location

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Immobilization

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Special Care

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MEDICATION

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OUTCOME

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Provisional Diagnosis

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ETD Triage

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Transport Status

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Destination Facility

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Destination Facility Type

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Destination Justification

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Medical Direction Doctor Name (if consulted)

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Deterioration During Transport

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INCIDENT REPORTING

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Response Delay

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Others

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Scene Delay

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Others

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Transport Delay

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Others

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VITAL SIGNS & OTHER OBSERVATIONS

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CPR TIME LOG

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CPR

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Bystander CPR

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Witnessed Arrest

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DNAR

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CPR Start

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CPR Cycle

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ROSC

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Outcome

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CPR End

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SAMPLER

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Sign & Symptom

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Allergy

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Medical

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Past Medical

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Last Meal

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Event leading to injury

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Risk Factor

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OTHER INFORMATION

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SIGNATURES

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