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Discipline

: Emergency

Sub Discipline

: Emergency

Document Title

: ETD Pre Hospital Care and Ambulance (PHC)

ASSIGN CALL CARD

Call Card No

Date Call Received

Event Code

Priority

Complaint

Incident Location

Landmark

Location Type

Distance to Scene

< 5 km

Caller Contact No

AMBULANCE INFORMATION

Response Team

Please Update Method

Dispatch Time

Enroute

At Scene

At Patient

Transporting

At Hospital

Reroute

Mission Abort

Arrive at scene no patient found

RESPONSE TEAM

Type of Service Response

999 Primary

Ambulance/Vehicle Registration Number

Response Team

Please Update Method

SCENE ASSESSMENT

PPE

Gown

Others

Environment

Safe

Case Type

Non-Trauma

Patient

Multiple

Backup

Required

Other Services Already at Scene

Police

Others

PATIENT INFORMATION

Patient Name

Id No.

Gender

Age

PATIENT ASSESSMENT

Appearance

Confused

Level of Responsiveness

Alert

Airway Patency

Adequate airway

Respiratory Effort

Normal

Air Entry

Right Lung

Absent

Left Lung

Absent

Breath Sound

Right Lung

Crepitation

Left Lung

Crepitation

Heart Sound

Muffled

Skin Assessment

Cold

Ecg

AF

Abdomen Palpation

Guarded

Abdomen Abnormality Location

Generalized

Stroke Scale (If applicable)

Balance

Abnormal

Face

Normal

Eye Sight

Abnormal

Speech

Normal

Arm

Normal

TRAUMA ASSESSMENT

Head

Abrasion

Face

Abrasion

Neck

Abrasion

Neck Abnormality Location

Anterior Right

Back

Abrasion

Back Abnormality Location

Thoracic Right

Spine

Deformity

Spine Abnormality Location

Sacral

Right Chest

Abrasion

Left Chest

Abrasion

Abdomen

Right Upper Quadrant

Abrasion

Left Upper Quadrant

Abrasion

Right Lower Quadrant

Abrasion

Left Lower Quadrant

Abrasion

Limb

Right Arm

Abrasion

Left Arm

Abrasion

Right elbow

Abrasion

Left elbow

Abrasion

Right Forearm

Abrasion

Left Forearm

Abrasion

Right wrist

Abrasion

Left wrist

Abrasion

Right Hand

Abrasion

Left Hand

Abrasion

Pelvic

Abrasion

Right hip

Abrasion

Left hip

Abrasion

Right Femur

Abrasion

Left Femur

Abrasion

Right Leg

Abrasion

Left Leg

Abrasion

Right knee

Abrasion

Left knee

Abrasion

Right ankle

Abrasion

Left ankle

Abrasion

Right Feet

Abrasion

Left Feet

Abrasion

INTERVENTION

Airway Device Intervention

ETT

Oxygen

BVM

External Haemorrhage Control Method

Bandage

Vascular Access

IO

Vascular Access Location

Immobilization

Cervical Collar

Special Care

Amputed limb care

MEDICATION

Medication Name

Please Update Method

OUTCOME

Provisional Diagnosis

ETD Triage

Green

Transport Status

Transported (resus)

Destination Facility

Destination Facility Type

Government hospital

Destination Justification

Nearest facility

Medical Direction Doctor Name (if consulted)

Deterioration During Transport

None

INCIDENT REPORTING

Response Delay

Direction/ unable to locate

Others

Scene Delay

Vehicle failure

Others

Transport Delay

Traffic

Others

VITAL SIGNS & OTHER OBSERVATIONS

Vital Signs & Other Observations

CPR TIME LOG

CPR

RequiredNot Required

Bystander CPR

No

Witnessed Arrest

No

DNAR

No

CPR Start

CPR Cycle

Please Update Method

ROSC

YesNo

Outcome

Transport

CPR End

SAMPLER

Sign & Symptom

Allergy

Medical

Past Medical

Last Meal

Event leading to injury

Risk Factor

OTHER INFORMATION

Extra Note

SIGNATURES

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