Instruction Manua Illinois EMS Preho Care Report Form

8/8/2019 Instruction Manua Illinois EMS Preho Care Report Form

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State of Illinois

Pat Quinn, Governor

Department of Public Health

Damon T. Arnold, M.D., M.P.H., Director

Instruction Manual for the

Illinois EMS PrehospitalCare Report Form

Form Version Dated April 2010

May 2010


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RecordofChangestothisDocument

ChangeDate Description Location

April2010 Initialrelease N/A

12May2010 Thedestinationhospitaltableisnowsortedbyhospitalnamerather

thanIDnumberandanewdestinationhasbeenadded(Deaconess

GatewayHospital,Newburgh,IN).

AppendixD


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InstructionManualfortheIllinoisEMSPrehospitalCareReportForm

Contents

Section1: TheLegalBasisforCollectingPrehospitalData....1

Section2:

General

Guidance2

Section3: ElementbyelementGuidance..3

Section4: Appendices

AppendixA: IllinoisCountyCodes.12 AppendixB: CodesforOutofstateCountiesBorderingIllinois..13 AppendixC: EMSSystemNumbersandResourceHospitalNamesandCities14 AppendixD: DestinationHospitalIDs,Names,andCities...15 AppendixE: Form..19


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IllinoisPrehospitalCareReportFormInstructionManualVersion1.1,May2010

IllinoisDepartment

of

Public

Health,

Division

of

EMS

and

Highway

Safety

1

Section1TheLegalBasisforCollectingPrehospitalData

TheIllinoisDepartmentofPublicHealthisauthorizedbytheIllinoisEMSAct,210ILCS50/3.195,andthe

EmergencyMedicalServiceandTraumaCenterCode,77IAC 515.350,tocollectprehospitalrunreportdata.

Fromthe

EMS

Act

(210

ILCS

50)

3.195.DataCollectionandEvaluation.

(a)TheDepartmentshalldevelopandadministeranemergencymedicalservicesdatacollectionsystem.

NothinginthisSectionshallbeconstruedtoempowertheDepartmenttospecifytheformofinternal

recordkeeping.

(b)TheconfidentialityofpatientrecordsshallbemaintainedinaccordancewithStateandfederal

regulationsonconfidentialityofrecords.

(c)TheDepartmentshalldevelopparametersbywhichtheavailabilityandqualityofemergencymedical

carecanbeevaluatedtoassureareasonablestandardofperformancebyindividualsandorganizations

providingsuchservices.

(d)EMSMedicalDirectorsshallhavetheauthoritytorequireSystemparticipantstoprovidedatatothe

SysteminadditiontothatrequiredbytheDepartment.Participantsshallnotberequiredtosubmit

financialinformationthatisproprietaryinnatureandunrelatedtothescopeorpurposesofthisAct.

FromIllinoisAdministrativeCode(77IAC)

515.350(excerpts)

a) Arunreportshallbecompletedbyeachvehicleserviceproviderforeveryemergencyprehospitalor

interhospitaltransportandforrefusalofcare.

1) Onecopyshallbeleftwiththereceivinghospitalemergencydepartment,traumacenteror

healthcare

facility

before

leaving

this

facility.

2) EachResourceHospitalEMSSystemshalldesignateorapproveasingleformtobeusedbyallof

itsvehicleproviders. Itshallbeaformthatcontainstheminimumprescribeddataelements

listedinSection515.AppendixEofthisPart.

/========================================================================/

c) TheambulanceprovidershallsubmittherunreportdatatotheResourceHospitalEMSSystem. Each

ResourceHospitalEMSSystemshallsubmitadatareporttotheDepartmentonMarch1,June1,

September1,andDecember1ofeachyear,coveringrunreportdatafromtheprecedingquarter. The

reportshallbeinoneofthefollowingformats:

1)

Copiesof

ascannable

run

report

form,

or

2) [Anelectronicfile]containingtheprescribeddataelements.

A) ThedataelementsshallbeinaformatcompatiblewiththeDepartment'sdatabaseinput

specifications,and

B) Departmentreviewandapprovalofdataformatcompatibilityisrequiredpriorto

submission.


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IllinoisDepartment

of

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Health,

Division

of

EMS

and

Highway

Safety

2

Section2GeneralGuidance

Theseinstructionsapplytotheonepage,twosidedcomputerformusedtocollecttheprehospitaldata

elementsprescribedbytheIllinoisDepartmentofPublicHealth. Thisformiscommonlyreferredasthe

bubblesheet.

Generalguidelinesforthesuccessfulcompletionandshipmentoftheforms:

Useblackorblueinktofillinthebubbles. Redink,inparticular,willnotberecognizedbythescanner. Errorsmaybecoveredusingcorrectionfluidorcorrectiontape. Iffluidisuseditshouldbeallowedtodry

completelybeforestackingtheforms.

Fillovalscompletely. Doughnuts,checkmarks,orsinglelinesthroughanovalwillnotberecognizedbythescanner.

Donottear,fold,orotherwisedamagetheform. Donotstapleotherdocumentstotheform,suchasnarrativedocumentation,orincludeotherloose

documentswiththeformsshipment;ensureallformsarefreeofstaples.

Donotwriteintheformmargins,oranywhereelseontheformexceptintheboxesandovalsdirectlyunderneath

each

of

the

blue

and

white

data

element

labels.

Ensurethattheformsaresecurelypackagedforshipping,especiallyiftheyarebeingsentbythecarton.Thiswillminimizeshippingdamagesuchascurledorcreasededges,tears,andformsthatdonotlieflat.

SendtheformstotheappropriateEMSSystemResourceHospitalor,withtheResourceHospitalspermission,directlytotheIllinoisDepartmentofPublicHealth:

IDPH/OPR/EMSandHighwaySafety

122SMichiganAve,Rm768

Chicago,IL60603

Attn: PrehospitalReportForms

Allreportsforrunsthatoccurinagivenquartershouldbepromptlyshippedaftertheendofthatquarter.Formsmaybesentmorebutnotlessoftenthanquarterly.

Additionalinformationabouttheform:

Whenadataelementcontainsheaderboxesabovecolumnsofovals,entertextintheboxesandfillintheovalbelowitthatcorrespondstothetextentry.

UnknownandNotApplicableresponsesareintendedonlyforuseinsituationsforwhichthosedescriptionstrulyapply. Theyshouldnotbeusedwhenmorespecificinformationisavailableand

applicable.

Whenenteringanumber,suchasatime,allavailablecolumnsforthenumbermustbecompleted,includingleadingzeros. Ifthetimetobeenteredis8:05AM,thecorrectentryis0805. Usemilitarytime,

sofor8:05PMthecorrectentryis2005.

Somedataelementswithmultiplechoicesallowmultipleentries,whileotherothersallowonlysingleentries. Refertotheelementbyelementinstructionsinthenextsectionformoreinformation.


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Section2ElementbyelementGuidance

Specificvalues/choicesformultiplechoicedataelementsarenotdefinedwhenselfevidentorassumedto

becommonknowledge.

Unlessotherwisenoted:

Anentryisrequiredforeachapplicabledataelementontheform; Onlyoneresponseshouldbeselectedformultiplechoicedataelements.

SideoneofformLITHOCODE: Theformserialnumberpreprintedonsideone,lowerrighthandside(noentryneeded).

DATE: Themonth,date,andyearthattheEMSresponsewasinitiated. Recordonlythelastdigitofthe

year.

AGENCYNO.: ThefourdigitEMSproviderlicensenumber(thefirstfourdigitsofthevehicleplatenumber).

Entrieswillbecheckedagainstknownagencylicensenumberswhentheformisscanned.

AvalidEMSagencylicensenumbermustberecordedonallrunreports,regardlessof

patient/incidentdisposition,includingcancellationsandrefusals.

VEH.#:The

two

digit

EMS

vehicle

number

(the

last

two

digits

of

the

vehicle

plate

number).

INCIDENTNUMBER: Thenumberassignedtotheincidentbythe911dispatchsystem.

INCIDENTCOUNTY: Enterthe5digitFederalInformationProcessingStandards(FIPS)codeforthecountyin

whichtheincidentoccurred. Thelastthreeofthefivedigitscomprisethecountyidentifier,andthefirsttwo

comprisethestateidentifier. ThestateidentifierforIllinoisis17. Forsurroundingstatesthestate

identifiersare:

Indiana18 Iowa19 Kentucky21 Missouri29 Wisconsin55

INCIDENTZIPCODE: ThefivedigitZIPcodefortheareainwhichtheincidentoccurred.

DISPATCHDELAY: Thereasonforadelayduringdispatch;ifnodispatchdelayselectNone.

DELAYS: ThismatrixcoversRESPONSEDELAY,SCENEDELAY,andTRANSPORTDELAY. Iftherewasadelay

duringone

or

more

of

these

stages

of

the

run

select

the

choice

in

the

appropriate

row

that

best

describes

thereasonforthedelay;wheneverthereisnodelayforastage,selectNoneforthatstage;recordN/A

forSCENEDELAYorTRANSPORTDELAYifeithertypeofdelaydoesnotapplyduetoacallcancellation,no

patientfoundatscene,etc.

TURNAROUNDDELAY: ReasontheEMSunitexperiencedadelayinachievingastateofreadinessforthe

nextcall;ifnoturnarounddelayselectNone.

RESPONSEMODE: Theunitslightsandsirensstatusonthewaytothescene.

SERVICEREQUESTED: TypeofservicetheEMSunitwasdispatchedtoprovide.

911Response(Scene)Emergentorimmediateresponsetoanincidentlocation,regardlessofmethodof

notification(forexample,911,directdial,walkintoagency,orflaggingdown).

Intercept

When

one

EMS

Provider

meets

atransporting

EMS

unit

with

the

intent

of

receiving

apatient

or

providingahigherlevelofcare.

InterfacilityTransferTransferofapatientfromonehospitaltoanotherhospital.

MedicalTransportAtransportthatisnotbetweentwohospitalsanddoesnotrequireanimmediate

response.

MutualAidArequestfromanotherambulanceservicetoprovideemergentorimmediateresponsetoan

incidentlocation.

StandbyAninitialrequestforservicethatwasnottiedtoapatientbuttoasituationwhereapersonmay

becomeillorinjured,suchasaparade,sportsevent,orotherlargepublicgathering.


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COMPLAINTREPORTEDBYDISPATCH: Theprimarycomplaintprovidedtotheunitbythe911dispatcher.

EMDPERFORMED: WhetherornotEmergencyMedicalDispatching(EMD)wasperformedbythe911

dispatcherand,ifso,whetherornotprearrivalinstructionswereprovidedtotheunit.

GENDER: Patientgender;completeYforpregnantwhenapplicable.

ETHNICITYandRACE: Theseareseparatecategoriesandbothfieldsshouldbecompleted. Baseselections

onwhatisselfreportedbythepatient,wheneverpossible.

PTDATEOFBIRTH: IfUNKisselectedforpatientdateofbirththenanestimateisrequiredinAGE. An

exactdateofbirthispreferabletoanestimateintheAGEfield.

WORKRELATED:Basetheresponseoninformationprovidedbythepatientorwitness. Ifthatisnot

available,anEMScrewmembersassessmentmaybeusediftheworkrelatedstatusisnotinquestion.

PTsOCCUPATIONALINDUSTRY: CompleteifWORKRELATEDisYes,otherwiseleaveblank.

AGE: AnentryisrequiredifnobirthdateisrecordedinthePT.DATEOFBIRTHfield,otherwiseAGEmaybe

leftblank. Alwayscompleteallthreedigits(forexample,16yearswouldbe016,2yearswouldbe002);

unitsarerecordedherealso. Usehours,days,months,oryearsasfollows:

Ifageislessthanoneday,usehours;otherwise Ifageislessthanonemonth,usedays;otherwise Ifageislessthantwoyears,usemonths;otherwise Forallotheragesuseyears.

PT.HOMEZIPCODE: Maybeleftblankifnotapplicable,suchaswithacancelledcallorifnopatientis

foundatthescene.

CREWMEMBER#1/#2/#3ID: ThestatelicensenumberforeachEMTB/I/Pcrewmemberassociatedwith

theEMSunitforwhichthereportisbeingcompleted,foruptothreecrewmembersbeginningwithCREW

MEMBER#1ID. Iffewerthanthreecrewmembers,leavetheremainingfield(s)blank. Entrieswillbe

checkedagainstvalidEMTB/I/Plicensenumberswhentheformisscanned.

INCIDENTLOCATIONTYPE: Thesettinginwhichtheincidentoccurred.

Home/Residence

Any

home,

apartment,

or

residence

(not

just

the

patient's

home).

Includes

ayard,

driveway,

garage,pool,garden,orwalkofahome,apartment,orresidence. Excludesassistinglivingfacilities.

FarmAplaceofagriculture,excludingafarmhouse;includeslandundercultivationandnonresidential

farmbuildings.

MineorQuarryIncludessandpits,gravelpits,ironorepits,andtunnelsunderconstruction.

IndustrialPlaceandPremisesAplacewherethingsaremade,assembled,constructed,stored,or

loaded/unloaded;includesconstructionsites,factories,warehouses,industrialplants,docks,andrailway

yards.

PlaceofRecreationorSportIncludesamusementparks,publicparksandplaygrounds,sports

fields/courts/courses,sportsstadiums,skatingrinks,gymnasiums,nonresidentialswimmingpools,

waterparks,andresorts.

StreetorHighwayAnypublicstreet,road,highway,oravenue,includingboulevards,sidewalks,ditches.

PublicBuilding(schools,governmentoffices)Anypubliclyownedbuildinganditsgrounds,including

schools,publicmuseums,andgovernmentoffices.

TradeorService(business,bars,restaurants,malls,etc.)Anyprivatelyownedbuildingusedforbusiness

andopentothepublic. Includesbars,restaurants,officebuildings,churches,stores,malls,bus/railway

stations. Excludeshealthcarefacilities.

IncidentLocationTypecontinuedonnextpage


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Highway

Safety

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INCIDENTLOCATIONTYPE(continued):

HealthCareFacility(clinic,hospital,nursinghome)Aplacewherehealthcareisdelivered,includes,clinics,

doctor'soffices,hospitalsand,undercertainconditions,nursinghomes*.

ResidentialInstitution(nursinghome,assistedliving,jail/prison)Aplacewherepeoplelivethatisnota

privatehome,apartment,orresidence. Includes,nursinghomes*,jails/prisons,orphanages,assistedliving

whenamedicalcareproviderisavailablebutdoesnotprovidepatientcareonaregularbasis,andgroup

homes.

Lake,River,OceanAnybodyofwater,exceptswimmingpools.

OtherLocationAnyplacethatdoesnotfitoneoftheabovecategories(useofthisselectionshouldbevery

rare).

#OFPTSATSCENE: UseMultipleEMSOverwhelmedtoindicateamasscasualtyincident(MCI). Forthe

purposesofthissystem,amasscasualtyincidentisaneventwhichincreasespatientvolumetotheextent

thatlocallyavailableemergencyandhealthcareresources,usingroutineprocedures,arerendered

inadequateandnonroutineassistancebecomesnecessary.

POSSIBLEINJURY: IndicateswhetherornotthereasonfortheEMSencounterwasrelatedtoeitheran

actualinjuryorananticipatedinjurybasedonmechanism(mechanismofinjuryhasbeendescribedasthe

wayinwhichthepersonsustainedtheinjury;howthepersonwasinjured;theprocessbywhichtheinjury

occurred,or;theeventsleadingtotheinjurysituation). Maybeleftblankonlyifnotapplicable,suchaswith

acancelledcallorifnopatientwasfoundatthescene.

INC.ONSET: Ifavailable,thefourdigitmilitarytime(24hourtime)whentheincident/injuryoccurredorthe

symptoms/problembegan,orareasonablyaccurateestimate. Exampleofmilitarytimeusage: For8:05AM,

record0805;for8:05PM,record2005. Maybeleftblank,buttrytoavoidthat. Incidentonsettimeis

importantclinicalinformation,especiallyforstroke,cardiac,andtraumapatients.

PSAPCALL: Ifavailable,thefourdigitmilitarytimewhenthepublicsafetyansweringpointreceivedthe911

call,orareasonablyaccurateestimate. Maybeleftblankifunknown,buttrytoavoidthatiftheinformation

isavailable.

UNITNOTIFIED: ThefourdigitmilitarytimewhentheEMSunitwasnotifiedoftheincidentbydispatch.

Mustbecompletedforallcalltypes.

UNITENROUTE: ThefourdigitmilitarytimewhentheEMSunitstartedgotunderway(vehiclestarted

moving). Mustbecompletedforallcalltypes.

UNITARRIVED: ThefourdigitmilitarytimewhentheEMSunitarrivedatthesceneoftheincident(vehicle

stoppedmoving). Maybeleftblankonlyifnotapplicable,suchaswithacallcancelledenroute.

ATPT.: ThefourdigitmilitarytimewhentheEMSunitarrivedatthepatientsside. Maybeleftblankonlyif

notapplicable,suchaswithacancelledcallorifnopatientwasfoundatthescene.

LEFTSCENE: ThefourdigitmilitarytimewhentheEMSunitleftthesceneoftheincident(vehiclestarted

moving). Requirediftherespondingunittransportedthepatient.

ARRIVEDDEST.:

The

four

digit

military

time

when

the

EMS

unit

arrived

with

the

patient

at

the

destination

ortransferpoint(vehiclestoppedmoving). Requirediftherespondingunittransportedthepatient.

BACKINSRVC: ThefourdigitmilitarytimewhentheEMSunitwasfinishedwiththecall,backinservice,

andavailableforthenextresponse(butnotnecessarilybackinitshomelocation). Mustbecompletedfor

allcalltypes.

*Iftheincidentoccursatanursinghomeandthepatientisalongtermresidentthere,thenselectResidentialInstitution;ifthe

incidentoccursatanursinghomeandthepatientisreceivingrehabilitationservicesorotherhealthcareandisnotalongterm

resident,thenselectHealthCareFacility.


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Highway

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BACKATHOME: ThefourdigitmilitarytimewhentheEMSunitwasbackinitsservicearea. Leaveblank

whentheunitdoesnotreturntoitsserviceareabetweencalls.

PRIMARYMETHODOFPAYMENT: BaseselectiononhowtheEMSproviderwillbereimbursedforthe

incidentratherthanonthetypeofinsurancethepatienthas.

CommercialInsurance Theincidentwillbebilledtoacommercialinsuranceplansuchashealthinsurance

orautoinsurancethatispaidforprivatelybythepatient,thepatientsfamily,orthepatientsemployer

(excludingWorkers

Compensation).

Medicaid TheincidentwillbebilledtoMedicaid,thestate/federalprogramthatpaysformedicalassistance

forindividualsandfamilieswithlowincomesandresources.

Medicare TheincidentwillbebilledtoMedicare,thefederalhealthinsuranceprogramforpeople65and

older,orpersonsunder65withcertaindisabilities.

OtherGovernment(notMedicare,Medicaid,orWorkersCompensation) Theincidentwillbebilledtoa

governmentinsurancepolicybesidesMedicare,Medicaid,orWorkersCompensation.

SelfPay/PatientHasNoInsurance Theincidentwillbebilledtothepatientdirectly,orthepatienthasno

insurancepolicythatwillpayforthisincident.

NotBilled(foranyreason) Thepatientwillnotbebilledatallforthisincident.

Unknown Theprimarymethodofpaymentwasnotknownatthetimetheprehospitalcaredatasheetwas

completed.

CMSSERVICELEVEL: CentersforMedicare&MedicaidServiceslevelofservice(airorground). Base

selectiononthemedicallynecessarytreatmentprovidedduringtransport(notethatgroundreferstoboth

landandwatertransportation).

Ground

BasicLifeSupport(BLS)

BLS,Emergency

AdvancedLifeSupport,Level1(ALS1)

ALS,Level1,Emergency

AdvancedLifeSupport,Level2(ALS2)

SpecialtyCareTransport(SCT)

Paramedic

ALS

Intercept

(PI)

Air

FixedWingAirAmbulance(Airplane)

RotaryWingAirAmbulance(Helicopter)

UseTBD(ToBeDetermined)ifCMSServiceLevelistobedeterminedafterthecompletionofthe

prehospitaldatasheet.

FormoreinformationaboutCMSServiceLevels,includingdefinitions,seeMedicareBenefitPolicyManual,

Chapter10AmbulanceServices,Subsection30.1CategoriesofAmbulanceServices(accessedat

http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdfon20June2009).

CONDITIONCODE: UsedbytheEMSproviderservicetocommunicatethepatientscondition,(asobserved

bytheambulancecrew)toaMedicarecontractororotheroversightauthority. Whereapplicable,select

eitherBLSorALSormajor(MAJ)orminor(MIN). Selectallthatapply.

Thefollowingtensituationrelateddataelements(precededby(S)inthismanual)maybeleftblankonlyif

notapplicable,suchaswithacancelledcallorifnopatientwasfoundatthescene.

(S)PRIORAID: Type(s)ofcareprovidedtothepatientbeforetheunitarrivedatthescene. Selectallthat

apply. Therearetworelateddataelements:

(S)PERFORMEDBY: Categoriesofpeoplewhoprovidedprioraid. Selectallthatapply.

(S)OUTCOME: Theoveralloutcomeofallprioraidreceivedbythepatient. Selectonlyone.

(S)CHIEFCOMPLAINTANATOMICLOCATION: Theprimaryanatomiclocationofthepatientschief

complaint,asidentifiedbyEMSpersonnel.


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(S)CHIEFCOMPLAINTORGANSYSTEM: Theprimaryorgansystemofthepatientschiefcomplaint,as

identifiedbyEMSpersonnel.

(S)SYMPTOMS(PRIMARY&OTHER): SymptomsobservedbyEMSpersonnel.

ThepatientsprimarysymptomisindicatedusinganovalcontainingtheletterP. Selectonlyone. Thepatientsothersymptom(s)is/areindicatedusingoneormoreovalscontainingtheletterO. Selectasmany

asapply.

Sidetwoofform(S)PROVIDERsIMPRESSION(PRIMARY&SECONDARY): EMSpersonnelsimpressionoftheprimaryand

secondaryproblems/conditionsleadingtothemedications,procedures,and/orothertreatmentprovidedto

thepatient.

EMSpersonnelsprimaryimpressionisindicatedusingoneoftheovalscontainingtheletterP. Selectonlyone. EMSpersonnelssecondaryimpressionisindicatedusingoneoftheovalscontainingtheletterS. Selectonly

one.

(S)MEDICALHISTORYOBTAINEDFROM: Categorizesthesourceofthepatientsmedicalhistory.

(S)BARRIERSTOPATIENTCARE: Selectallthatapply.

(S)ALCOHOL/DRUGUSEINDICATORS: Documentsthepresenceofpotentialdrugoralcoholuseindicators

associatedwith

the

patient;

not

intended

to

document

whether

EMS

personnel

knew

with

certainty

that

the

patientwasaffectedbydrugsand/oralcoholatthetimeoftheincident. Selectallthatapply.

IftheselectionforthePOSSIBLEINJURYdataelementisYesthenthefollowingtwodataelements

(precededby(I)inthismanual)mustalwaysbecompleted.Also, iftheselectionforthePOSSIBLEINJURY

dataelementisYesandtheselectionforCAUSEOFINJURYiseitherMotorvehicletrafficaccidentorMotor

vehiclenontrafficaccident,thenthefivedataelementsprecededby(IMVA)inthismanualmustbealsobe

completed.

(I)CAUSEOFINJURY: Thecategoryofthereportedorsuspectedcauseofinjury. Selectonlyone. If

multiplecausesapply,choosetheonemostcloselyrelatedtotheprimaryreasonfortheresponseand/or

thetype

of

care

given.

ForamotorvehicleincidentoccurringonapublicroadorhighwayselectMotorvehicletrafficaccident; ifthe

incidentoccursentirelyoffofpublicroadwaysorhighwaysselectMotorvehiclenontrafficaccident.

SelectBicycleAccidentwhenamotorizedvehicleisnotinvolved;foraccidentsinvolvingamotorvehicleandabicycleselecteitherMotorvehicletrafficaccidentorMotorvehiclenontrafficaccidentbasedonwhetherornot

theincidentoccurredonapublicroad/highway.

Foradrowning/neardrowningrelatedtowatercraftselectWaterTransport;forotherdrowning/neardrowningincidentsselectDrowning.

RadiationExposureexcludescomplicationsofradiationtherapy.(I)USEOFOCCUPANTSAFETYEQUIP.: Safetyequipmenttype(s)inusebythepatientatthetimeofthe

injury. Selectallthatapply.

(IMVA)AIRBAGDEPLOYMENT: Whetheranairbagwaspresent;ifpresent,whetheritdeployed;if

deployed,whattype(s). MultipleselectionsallowedundertheDeployedsubheadingonly.

(IMVA)VEHICULARINJURYINDICATORS: Physicalevidenceassociatedwiththevehicleinvolvedinthe

motorvehicleaccidentcausingtheinjury. Theseindicatorsarerelatedtoinjurypatternsandhaveaclinical

application. Selectallthatapply.


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(IMVA)POSITIONOFPT.INVEHICLE: Twopiecesofinformationarecollectedinthisfield.

Thepatientsseatrowlocationinthevehicleatthetimeofthecrash;thesystemrecognizesupto50seatrows(01through50)toaccommodatevans,buses,etc;thefrontseatrowis01;todesignatea

cargoareaenteranynumbergreaterthan50.

Thepatientlocationwithinaseatrowatthetimeofthecrash: left(nondriver),right,middle,driver).(IMVA)LAWENFORCEMENT/CRASHREPORTNUMBER: Theuniquenumberassociatedwiththelaw

enforcement/crash

report

associated

with

the

incident.

Important

for

crash

outcome

data

linkage.

CARDIACARREST: Whetherornotthepatientexperiencedacardiacarrestand,ifso,whetheritoccurred

beforeorafterthearrivalofanEMSunit. Asindicatedintheshadedboxbelow,ifaYesvalueisselected

forthisdataelementthenthefiveothercardiacelementsmustbecompleted.

IftheresponsefortheCARDIACARRESTdataelementisoneofthetwoYesvaluesavailableforthat

elementthenthefivecardiacdataelementsprecededby(C)inthismanualmustbecompleted. Ifthe

responsefortheCARDIACARRESTdataelementisNothenthesefiveelementsleftblank.

(C)CARDIACARRESTETIOLOGY: Theproximatecauseofthecardiacarrest.

(C)ANYRETURNOFSPONTANEOUSCIRCULATION: AppliestoanytimeduringtheEMSevent.

(C)RESUSCITATION

ATTEMPTED:

Whether

resuscitation

was

attempted;

ifso,

what

type;

if

not,

why

not.

Selectallthatapply.

(C)ARRESTWITNESSEDBY: Whetherarrestwaswitnessedand,ifso,whetherbyahealthcareprovideror

layperson.

(C)FIRSTMONITOREDRHYTHMOFTHEPATIENT: Documentsthefirstmonitoredrhythmafteracardiac

arrest.

CARDIACRHYTHM: ThecardiacrhythminterpretedbyEMSpersonnelaspartofaroutinepatient

assessment. Thiselementispartofvitalsignsandisnotoneofthecardiacarrestelements. UsetheFIRST

MONITOREDRHYTHMOFTHEPATIENTdataelementtorecordthefirstcardiacrhythmidentifiedaftera

cardiacarrest.

Alwaysenterathreedigitnumberwhenrecordingdataforthefollowingfivevitalsignsdataelements;usea

leadingzeroifnecessary(e.g.,forapulserateof72,record072);ifaparticularvitalsignwasnottaken,

leaveitblank:

SYSTOLIC(mmHg)

DIASTOLIC(mmHg)

PULSE(perminute)

PULSEOX(percentage)

RESPIRATION(perminute)

WEIGHT: Athreedigitestimatedpediatricbodyweightmustberecordedforpatientsyoungerthan16(use

aleadingzeroifnecessary);provideanestimateiftheactualweightisunknown. Selectunits(poundsor

kilograms;kilogramsarepreferred).

GLASGOWCOMASCALE: Entriesmustberecordedforallthreecomponentscores(eye,verbal,motor)forthesystemtocalculateatotalscore.

Fortheverbalcomponenttherearethreeseparatesetsofvalues,oneforpatientslessthan2yearsold,oneforpatients25yearsolder,andoneforpatientsolderthan5. Usethesetofvaluesthatis

appropriateforthepatientsage.

Ifselectingascoreof6forthemotorcomponent,choseeither6a(patientisolderthan5years)or6b(patientisfiveyearsoryounger).


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STROKESCALE: Performedwhenastrokeissuspected. Selectthetypeofstrokescale(CincinnatiorLA)

andtheresultsoftheassessment. Ifanassessmentisnotcompletedbecauseastrokeisnotsuspected,

selectN/A.

THROMBOLYTICSCREEN: Indicatecontraindicationstothrombolyticusebasedonpatientscreening. Select

N/Aifdeemedunnecessary. SelectUnknownifavailableinformationwasinsufficientforscreening.

The

three

medication

data

elements

preceded

by

(M)

in

this

manual

must

be

completed

when

a

medication

is

giventothepatientbyEMSpersonnel. Ifnomedicationwasgivenallthreeoftheseelementsshouldbeleft

blank.

(M)MEDICATIONGIVEN&ADMINISTEREDROUTE: ThemedicationsgiventothepatientbyEMS. Selectall

thatapply.

Selectallmedicationsgivenbyfillingintheovaltotherightofthemedicationnamecontainingtheadministrationrouteabbreviation. Theroutesavailableforeachmedicationweredeterminedbythe

StateofIllinoisEMSMedicalDirectorandEMSandHighwaySafetyDivisionChiefusinggenerally

acceptedreferencematerials.

SelectanadministrationrouteforOtherifamedicationgiventothepatientisnotlistedamongthoseon

the

form.

ThefollowingmedicationroutetableisalsoprintedontheformnexttotheROUTELEGENDheading:ET=Endotracheal

IH=Inhalation

IM=Intramuscular

IN=Intranasal

IO=Intraosseous

IV=Intravenous

PO=Peros(bymouth)

RCT=Rectal

SC=Subcutaneous

SL=Sublingual

TOP=Topical

Ifthereisamedicationcomplication,fillintheovalcontainingtheletterCtotheleftofnameofthemedicationassociatedwiththecomplication. Indicate,atmost,onlyonemedicationcomplicationper

runreport.Iftherearecomplicationsassociatedwithmorethanonemedication,fillintheCovalonly

forthemedicationassociatedwiththemostseriouscomplication.

(M)MEDICATION

COMPLICATION:

If

amedication

complication

was

identified

by

filling

in

the

oval

containingtheletterCtotheleftofnameofamedication,identifythetypeofcomplicationhere. Select

onlyone.

(M)MEDICATIONAUTHORIZATION: Thetypeoftreatmentauthorizationobtained. Selectonlyone.

PROCEDURES: Theprocedure(s)performedonthepatientbyEMS. Selectallthatapply. Certain

procedureshavefourovalstotheleftoftheprocedurename. Completetheseasfollows:

Forallproceduresperformed,fillintheovaltotheleftoftheprocedurenamecontainingthenumberofattempts,1foroneattempt,and2+formorethanoneattempt.

Ifunabletosuccessfullycompleteaprocedure,fillintheovaltotheleftoftheprocedurenamecontainingtheletterU.

Ifacomplicationisassociatedwithaprocedure,fillintheovalcontainingtheletterCtotheleftofnameoftheprocedure. Indicate,atmost,onlyoneprocedurecomplicationperrunreport. Ifthereare

complicationsassociatedwithmorethanoneprocedure,fillintheCovalonlyfortheprocedure

associatedwiththemostseriouscomplication.

Ifaprocedurehasonlyoneovaltotheleftoftheprocedurename,simplyfillinthatovaliftheprocedure

wasperformed.

PROCEDURECOMPLICATION: Ifaprocedurecomplicationwasidentifiedbyfillingintheovalcontainingthe

letterCtotheleftofnameofaprocedure,identifythetypeofcomplicationhere. Selectonlyone.


14/24


IllinoisDepartmentofPublicHealth,DivisionofEMSandHighwaySafety 10

PROCEDUREAUTHORIZATION: Thetypeofprocedureauthorizationobtained. Selectonlyone.

REASONFORCHOOSINGDESTINATION: Whythepatientwastransportedortransferredtotheselected

destination.

SpecialtyResourceCenterTransportedtoaspecialtyfacilitybaseduponuniqueneedsofthepatient,

whetherornotthiswastheclosestfacility.

PatientRequestTransportedtohospital/facilityofpatientschoice.

FamilyRequest

Transported

to

hospital/facility

chosen

by

the

patients

family

or

aperson

acting

on

the

patientsbehalf.

LawEnforcementRequestTransportedtohospital/facilitychosenbyLawEnforcement.

Patient'sPhysiciansRequestTransportedtohospital/facilitychosenbythepatientsphysician.

OnLineMedicalDirectionTransportedtohospital/facilityasdirectedbymedicalcontroleitheronlineor

onscene.

DiversionThefirstchoiceforhospital/facilitywasunabletoacceptthepatient.

ProtocolTransportedtoalternatefacilityinaccordancewithMedicalDirectorapproved

protocols/guidelines.

InsuranceStatusThehospital/facilitywaschosenbasedoninsurancecoverage.

ClosestFacility

Transported

to

the

closest

hospital/facility.

OtherNotoneoftheotheroptionslisted.

NotApplicableTherespondingunitdidnottransportthepatient.

DESTINATIONTYPE: Thetypeofdestinationtowhichthepatientwastransportedortransferred.

INCIDENT/PATIENTDISPOSITION: Thepatientstreatmentand/ortransportstatusatthetimeEMS

involvementconcluded. Thisiscriticalinformationandmustbecompletedforallcalltypes.

TransportedbyEMS ThepatientwastreatedandtransportedbythereportingEMSunit.

TransportedbyLawEnforcement Thepatientwastreatedandtransportedbyalawenforcementunit.

TransportedbyPrivateVehicle ThepatientwastreatedandtransportedbymeansotherthanEMSorlaw

enforcement.

Treated,Transferred

Care

The

patient

was

treated

but

care

was

transferred

to

another

EMS

unit.

TreatedandReleased ThepatientwastreatedbyEMSbutdidnotrequiretransporttothehospital.

PatientRefusedCareThepatientrefusedtogiveconsentorwithdrewconsentforcare.

Notreatmentrequired Assessmentofthepatientresultedinnoidentifiableconditionrequiringtreatment

byEMS.

NoPatientFound EMSwasunabletofindapatientatthescene.

DeadatSceneThepatientwaseitherdeadonarrivalordeadafterarrivalwithfieldresuscitationnot

successfulandnottransported.

CancelledTheresponsewascancelledpriortopatientcontact.

TRANSPORTMODEFROMSCENE: Theunitslightsandsirensstatusonthewayfromthescenetothe

destination.

Completefor

patient

transports/transfers

only.

PERSONALPROTECTIVEEQUIPMENTUSED: Selectallthatapply. Ifatypeofpersonalprotectiveequipment

wasusedthatisnotontheformselectOther.

DESTINATION/TRANSFERREDTO,CODE: Thefourdigitdestinationhospitalcode. Acompletelistof

destinationhospitalnamesandcodescanbeaccessedathttp://www.emsdata2.com/ILNEMSIS/. Usefor

transportsfromasceneaswellasinterfacilitytransports. Ifthetransportdestinationwasotherthana

hospitalorifthepatientwasnottransportedthisfieldshouldbeleftblank.


15/24



DESTINATIONZIPCODE: ThefivedigitZipCodeinwhichthepatienttransportdestinationislocated. Use

fortransportsfromasceneaswellasinterfacilitytransports. Ifthetransportdestinationwasahospitalor

ifthepatientwasnottransportedthisfieldshouldbeleftblank.

EMSSystemNumber: ThefourdigitnumberidentifyingwhichtheEMSSystemunitwasoperatingunder. A

completelistofResourceHospitalsandassociatedEMSSystemnumberscanbeaccessedat

http://www.emsdata2.com/ILNEMSIS/.

TheEMS

System

number

must

be

completed

on

all

run

reports,

regardless

of

patient/incident

disposition,includingcancellationsandrefusals.


16/24



AppendixA:IllinoisCountyCodesThestatecodeforIllinoisis17. Enterthefivedigitcombinedstateandcountycodeontheform. For

example,thecorrectentryforDuPageCounty,Illinoisis17043.

CODENAME

CODE

NAME

CODE

NAME

001 Adams 071 Henderson 141 Ogle

003 Alexander 073 Henry 143 Peoria

005 Bond 075 Iroquois 145 Perry

007 Boone 077 Jackson 147 Piatt

009 Brown 079 Jasper 149 Pike

011 Bureau 081 Jefferson 151 Pope

013 Calhoun 083 Jersey 153 Pulaski

015 Carroll 085 JoDaviess 155 Putnam

017Cass

087

Johnson

157

Randolph

019 Champaign 089 Kane 159 Richland

021 Christian 091 Kankakee 161 RockIsland

023 Clark 093 Kendall 163 St.Clair

025 Clay 095 Knox 165 Saline

027 Clinton 097 Lake 167 Sangamon

029 Coles 099 LaSalle 169 Schuyler

031 Cook 101 Lawrence 171 Scott

033 Crawford 103 Lee 173 Shelby

035

Cumberland

105

Livingston

175

Stark

037 DeKalb 107 Logan 177 Stephenson

039 DeWitt 109 McDonough 179 Tazewell

041 Douglas 111 McHenry 181 Union

043 DuPage 113 McLean 183 Vermilion

045 Edgar 115 Macon 185 Wabash

047 Edwards 117 Macoupin 187 Warren

049 Effingham 119 Madison 189 Washington

051 Fayette 121 Marion 191 Wayne

053 Ford 123 Marshall 193 White

055Franklin

125

Mason

195

Whiteside

057 Fulton 127 Massac 197 Will

059 Gallatin 129 Menard 199 Williamson

061 Greene 131 Mercer 201 Winnebago

063 Grundy 133 Monroe 203 Woodford

065 Hamilton 135 Montgomery

067 Hancock 137 Morgan

069 Hardin 139 Moultrie


17/24



AppendixB:CodesforOutofstateCountiesBorderingIllinois

Thestatecodeisgiveninparenthesisafterthestatename. Enterthefivedigitcombinedstateandcounty

codeontheform. Forexample,thecorrectentryforLakeCounty,Indianais18089.

Indiana(18)

007 Benton

051 Gibson

083 Knox

089 Lake

111 Newton

129 Posey

153 Sullivan

165 Vermillion

167

Vigo

171 Warren

Iowa(19)

005 Allamakee

043 Clayton

045 Clinton

057 DesMoines

061 Dubuque

097

Jackson

111 Lee

115 Louisa

139 Muscatine

163 Scott

Kentucky(21)

007 Ballard

055 Crittenden

139

Livingston145 McCracken

225 Union

Missouri(29)

031 CapeGirardeau

045 Clark

099 Jefferson

111 Lewis

117 Lincoln

127 Marion

133 Mississippi

157 Perry

163

Pike

173 Ralls

183 SaintCharles

186 SainteGenevieve

189 SaintLouis

201 Scott

Wisconsin(55)

043 Grant

045

Green

059 Kenosha

065 Lafayette

105 Rock

127 Walworth


18/24


IllinoisDepartment

of

Public

Health,

Division

of

EMS

and

Highway

Safety

14

AppendixC: EMSSystemNumbersandResourceHospitalNamesandCities

0121 St.AnthonyMedCtr,Rockford

0134 KatherineShawBethea,Dixon

0139 RockfordMemorial,Rockford

0165 KishwaukeeComm,DeKalb

0175 SwedishAmerican,Rockford

0215 TrinityMedicalCenter,RockIsland

0218 StFrancisMedicalCtr,Peoria

0219 McDonoughDistrict,Macomb

0237 BroMennRegMedCtr.,Normal

0238 St.JosephMed.Ctr.,Blm

0240

KewaneeHospital,

Kewanee

0242 St.Mary'sHosp,Galesburg

0243 GalesburgCottageHosp,Galesburg

0245 St.Mary'sHosp,Streator

0253 GenesisHospital,Silvis

0254 IllinoisValleyCommHosp,Peru

0256 OttawaRegHosp&HCCtr,Ottawa

0257 St.JamesHosp,Pontiac

0316 St.John'sHosp,Springfield

0320 BlessingHospital,Quincy

0324 PassavantHosp,Jacksonville

0327 MemorialMedCtr,Springfield

0360 JerseyCommunityHosp,Jerseyville

0425 MemorialHospital,Belleville

0432 AndersonHosp,Maryville

0451

Alton

Memorial

Hosp,

Alton

0473 St.Anthony'sHealthCtr,Alton

0476 GreenvilleRegHosp,Greenville

0526 GoodSamaritan,Mt.Vernon

0530 MemorialHospital,Carbondale

0550 MassacMemHosp,Metropolis

0562 HeartlandHospital,Marion

0564 FairfieldMemHosp,Fairfield

0623 StMary's,Decatur

0633 SaraBushLincoln,Mattoon

0644 CarleFoundation,Urbana

0663 CrawfordMemHosp,Robinson

0671 ProvenaCovenantMedCtrUrbana

0704 IngallsMemorialHosp,Harvey

0710 SilverCrossHosp,Joliet

0712 StMary'sKankakee

0729 ChristHospital,OakLawn

0746

RiversideMedical,

Kankakee

0805 LoyolaUnivMedCtr,Maywood

0828 GoodSamaritan,DownersGrove

0849 CentralDuPageHosp.Winfield

0859 EdwardHospital,Naperville

0906 CentegraNIMC,McHenry

0907 NorthwestComm,ArlingtonHts

0909 ShermanHospital,Elgin

0948 DelnorCommunity,Geneva

0961 StJoseph's,Elgin

1002 HighlandParkHosp,HighlandPark

1011 StFrancis,Evanston

1014 VistaMedCtrEast,Waukegan

1072 CondellMedlCtr,Libertyville

1103 IllinoisMasonicMedCtr,Chgo

1108

Northwestern

Memorial,

Chgo

1113 UnivofChicagoHosp,Chicago

1236 MercyHealthcare,Dubuque

1241 UnionHospital,TerreHaute

1255 St.Mary's,Evansville,IN

1275DeaconessHospital,EvansvilleIN


19/24


IllinoisDepartment

of

Public

Health,

Division

of

EMS

and

Highway

Safety

15

AppendixD: DestinationHospitalIDs,Names,andCities**CitynotlistedforChicagohospitals. IDnumbersforallhospitalslocatedwithinChicagoscitylimitsbeginwiththenumbersix.

ID HospitalNameandCity

0578 AbrahamLincolnMemorialHosp, Lincoln

1031 AdventistBolingbrookHospital

0146

AdvocateChrist

Med

Ctr,

Oak

Lawn

0507 AdvocateCondellMedCtr, Libertyville

0508 AdvocateGoodShepherdHosp, Barrington

6058 AdvocateTrinityHosp, Chicago

0145 AlexianBrothersMedCtr, ElkGroveVillage

0653 AltonMemorialHospital

0655 AndersonHosp, Maryville

9628 BarnesJewish WestCoHospital,StLouisMO

9632 BarnesJewishHospital, StLouisMO

6004

BethanyHospital

0001 BlessingHospitalAt11ThStr,Quincy

0003 BlessingHospitalAt14Street,Quincy

0615 BromennRegionalMedCtr, Normal

9630 CardinalGlennonChildrens, StLouis MO

0083 CarleFoundationHospital,Urbana

0641 CarlinvilleAreaHospital

1003 CarmiTownshipHospital

9620 CenterPointeHosp, StCharlesMO

0236 CentralDupageHosp, Winfield

1014

CghMed

Ctr,

Sterling

6017 ChildrensMemorialHospital

9612 ChristianHospNortheast, StLouisMO

0110 ClayCountyHospital,Floria

6026 ColumbiaGrantHospital

6019 ColumbusHospital

0642 CommunityMemorialHospital,Staunton

0190 CrawfordMemorialHosp, Robinson

0416 CrossroadsCommunityHosp, MtVernon

9453

Deaconess

Hosp,

Evansville

IN

9636 DeaconessHosp, StLouisMO

9457 DeaconessGateway&Women'sHosps,

NewburghIN

0629 DecaturMemorialHospital

0460 DelnorCommunityHosp, Geneva

9624 DepaulHealthCtr, StLouisMO

9629 DesPeresHospital, StLouisMO

6030 DoctorsHospOfHydePark


0214 Dr.JohnWarnerHosp, Clinton

6022 EdgewaterHospitalAndMedicalCtr

0237 EdwardHosp,

Naperville

0238 ElmhurstMemorialHospital

1067 EurekaCommunityHospital

0992 FairfieldMemorialHospital

0275 FayetteCountyHosp, Vandalia

0860 FerrellHosp, Eldorado

9532 FinleyHosp, DubuqueIA

0299 FranklinHosp, Benton

0909 FreeportMemorialHospital

0438 GalenaStauss

Hospital,

Galena

0493 GalesburgCottageHospital

0657 GatewayRegionalMedCtr, GraniteCity

0831 GenesisMedCtrIlliniCampus, Silvis

0287 GibsonCommunityHosp, GibsonCity

0239 GlenoaksMedCtr, GlendaleHeights

0240 GoodSamaritanHosp,DownersG.

0415 GoodSamaritanRegHc, MtVern

0152 GottliebMemorialHosp, MelrosePark

0311 GrahamHosp, Canton

0025 GreenvilleRegional

Hospital

0345 HamiltonMemorialHosp, Mcleansboro

0379 HammondHenryHosp, Geneseo

0368 HardinCountyGeneralHosp, Rosiclare

0861 HarrisburgMedicalCenterInc

1041 HeartlandRegionalMedCtr, Marion

1040 HerrinHospital

0717 HillsboroAreaHospital

0153 HinesVeteransAdministrationHosp

0241 Hinsdale

Hospital6028 HolyCrossHospital

0154 HolyFamilyMedCtr, DesPlain

0944 HoopestonCommunityMemorial

0920 HopedaleHospital

0791 IlliniCommunityHosp, Pinckneyville

6032 IllinoisMasonicMedicalCenter

0527 IllinoisValleyCommunityHosp, Peru


20/24


IllinoisDepartment

of

Public

Health,

Division

of

EMS

and

Highway

Safety

16


0002 IllinoisVeteransHome, Quincy

0156 IngallsMemorialHosp, Harvey

0392 IroquoisMemorialHosp, Watseka

6034 JacksonParkHospital&Medic

9625 JeffersonMemorialHosp, FestusMO

0427 JerseyCommunityHosp, Jerseyville

9635 JewishHospitalOfStLouis,MO

0780 John&MaryE.KirbyHosp, Monticello

6020 JohnHStrogerHosp(CookCo)

6021 JohnHStrogerHospPedTrauma

0552 KatherineShawBetheaHosp, Dixon

0848 KennethHallRegionalHosp, EastStLouis

0380 KewaneeHospital

0203 KindredHosp, Sycamore

6003

KindredHosp,

Chicago

(Central)

6068 KindredHospital(NorthCampus), Chicago

0172 KindredHospital, Northlake

6056 KindredHospitalLakeshore, Chicago

0201 KishwaukeeCommunityHosp, Dekalb

0147 LagrangeCommunityHospital,Lagrange

0510 LakeForestHospital

6035 LarabidaChildrensHosp

0541 LawrenceCoMemorialHosp, Lawrenceville

0878 LincolnPrairieBehavioralHealthCtr,

Springfield

0157 LittleCompanyOfMaryHosp, EvergreenPark

6036 LorettoHospital

6037 LouisA.WeissMemorialHospital

0150 LoyolaUniversityMedCtr, Maywood

0160 LutheranGeneralHosp, ParkRidge

0161 MacnealMemorialHosp, Berwyn

0768 MarshallBrowningHosp, DuQuoin

0683 MasonDistrictHosp, Havana

0694

Massac

Memorial

Hosp,

Metropolis

0085 McKinleyMemorialHosp, Urbana

0591 McDonoughDistrictHosp, Macomb

0403 MemorialHospitalOfCarbonda

0846 MemorialHospital, Belleville

0357 MemorialHospital, Carthage

0803 MemorialHospital, Chester

0875 MemorialMedCtr, Springfield


0603 MemorialMedCtr, Woodstock

0528 MendotaCommunityHospital

0705 MercerCountyHosp, Aledo

0602 MercyHarvardHosp

9531 MercyHealthCtr, DubuqueIA

6041 MercyHosp&MedCtr, Chicago

9510 MeriterHospital, MadisonWI

6005 MethodistHospitalOfChicago

0755 MethodistMedCtrOfIl, Peoria

0174 MetrosouthMed Ctr, BlueIsland

6042 MichaelReeseHospit

0506 MidwesternRegionalMedCtr, Zion

9639 MilwaukeeChildrensHospital,WI

9613 MissouriBaptist, ChesterfieldMO

0334 MorrisHospital

1015 MorrisonCommunityHospital

6043 Mt.SinaiHospitalMedicalCenter

7061 NonSpecIllinois

7045 NonSpecIndiana

7053 NonSpecIowa

7047 NonSpecKentucky

7052 NonSpecMinnesota(Inc.Mayo)

7063 NonSpecMissouri

7051 NonSpecWisconsin

0604 NorthernIllinoisMedCtr, McHenry

0148 NorthshoreEvanstonHospital

0151 NorthshoreGlenbrookHosp, Glenview

0509 NorthshoreHighlandParkHosp

0170 NorthshoreSkokieHospital

0162 NorthwestCommunityHosp, ArlingtonHeights

0036 NorthwestSuburbanHospital,Belvidere

6045 NorthwesternMemorialHospital

9470 NortonHosp, LouisvilleKY

6046 NorwegianAmerican

Hosp,

Inc.

0164 OakForestHospital

0165 OakParkHospital

0969 OsfHolyFamilyMedCtr, Monmouth

0757 OsfStFrancisMedCtr, Peoria

0495 OsfSt.MaryMedCtr, Galesburg

0526 OttawaRegHosp&HcCtr

6044 OurLadyOfTheResurrection


21/24


IllinoisDepartment

of

Public

Health,

Division

of

EMS

and

Highway

Safety

17


0168 PalosCommunityHosp, PalosHeights

0098 PanaCommunityHospital,Pana

0253 ParisCommunityHospital

0732 PassavantAreaHosp, Jacksonville

0921 PekinMemorialHospital

0048 PerryMemorialHospital,Princeton

0769 PinckneyvilleCommunityHospital

0756 ProctorCommunityHosp, Peoria

0086 ProvenaCovenantMedCenter,Urbana

0466 ProvenaMercyMedCtr, Aurora

0468 ProvenaSaintJosephHosp.Elgin

1028 ProvenaStJosephMedCtr, Joliet

0482 ProvenaSt.MarysHosp, Kankakee

0945 ProvenaUnitedSamaritansMedCtr, Danville

6047

ProvidentHospital

Of

Cook

Co

6048 RavenswoodHospitalMedicalC

0807 RedBudRegionalHospital

6050 ResurrectionMedicalCenter

0818 RichlandMemorialHosp, Olney

9450 RileysChildrensHosp, IndianapolisIN

0169 RiveredgeHospital, ForestPark

0480 RiversideMedCtr, Kankakee

0743 RochelleCommunityHospital

1054 RockfordMemorialHospital

6052 RoselandCommunityHospital

0461 RushCopleyMemorialHosp, Aurora

6053 RushUniversityMedCtr, Chica

6025 SacredHeartHospital

0656 SaintAnthonysHosp, Alton

0658 SaintClaresHosp, Alton

0566 SaintJamesHosp, Pontiac

0037 SaintJosephHosp, Belvidere

0671 SalemTownshipHospital

0134

SarahBush

Lincoln

Health

Center,

Mattoon

0887 SarahD.CulbertsonMemorial, Rushville

0849 ScottAirForceMedCtr, Belleville

0898 ShelbyMemorialHosp, Shelbyville

0467 ShermanHospitalAss'N, Elgin

6057 ShrinersHospitalForCripple

1027 SilverCrossHosp, Joliet

6059 SouthShoreHospital(Luella)


0171 SouthSuburbanHosp, HazelCrest

9638 SoutheastHospital,CapeGirardeauMO

0806 SpartaCommunityHospital

9614 SsmStClare, FentonMO

0155 StAlexiusMedCtr, HoffmanEstates

1055 StAnthonyMedCtr, Rockford

9626 StAnthonys MedCtr, StLouisMO

0167 StJamesMed.Ctr. OlympiaFields

9611 StLukesHospital, ChesterfieldMO

9455 StMargaretMercy, DyerIN

9452 StMargaretMercy, HammondIN

6066 StMary&ElizabethMedCtr

9451 StMarys MedCtr, EvansvilleIN

9622 St.AlexiusHosp, StLouisMO

6061 St.Anthony

Hospital,

Chicago

0264 St.Anthonys MemHosp, Effingham

6062 St.Bernards Hosp, Chicago

6063 St.Elizabeths Hospital, Chicago

0847 St.Elizabeth's Hosp, Belleville

0173 St.FrancisHospital, Evanston

0718 St.FrancisHospital, Litchfield

0175 St.JamesHospital,ChgoHts

0876 St.Johns Hosp, Springfield

9610 St.Johns MercyMc, StLouisMO

9623 St.JosephHealthCtr, StCharlesMO

6065 St.JosephHospital, Chicago

0617 St.JosephMedCtr, Bloomington

0404 St.JosephMemorialHosp, Murphysboro

0659 St.Josephs Hosp, Highland

0122 St.Josephs Hospital,Breese

9631 St.LouisChildrensHospital,MO

9621 St.LouisUniversityHospital,MO

0049 St.Margarets Hospital,SpringValley

9633 St.Marys Hlth

Ctr,

St

Louis

MO

0672 St.Marys Hospital, Centralia

0630 St.Marys Hospital, Decatur

0530 St.Marys Hospital, Streator

0176 SuburbanHosp&Sanitarium, Hinsdale

1056 SwedishAmericanHosp, Rockford

6067 SwedishCovenantHospital

0099 TaylorvilleMemorialHosp


22/24


IllinoisDepartment

of

Public

Health,

Division

of

EMS

and

Highway

Safety

18


0322 ThomasHBoydMemorialHosp, Carrollton

6069 ThorekHospital&MedicalCenter

0844 TouchetteRegionalHosp, Centreville

0830 TrinityMedCtrWest, RockIsland

0833 TrinityMedCtr7ThSt, Moline

0512 USArmyInfirmary,HighlandPark

0513 USNavyHospital,GreatLakes

0933 UnionCountyHospital, Anna

9454 UnionHospital, TerraHauteIN

6072 UnivOfIllinoisHospital

6071 UniversityOfChicagoMedCtr

9530 UniversityOfIowa,IowaCityIA

9634 UniversityOfMissouriClinics

0202 ValleyWestHosp, Sandwich


6073 VetAdminLakesideMedCenter

6074 VetAdminWestSideMedCtr

0947 Veterans AdminFacility, Danville

0514 VeteransAdmHospNorthChicago

1042 VetsAdminMedCtr, Marion

0511 VistaMedCtr West, Waukegan

0515 VistaMedCtrEast, Waukegan

0958 WabashGeneralHosp, MtCarmel

0981 WashingtonCountyHosp, Nashville

9456 WelbornBaptistHosp, Evansville IN

0178 WestSuburbanMedCtr, OakPark

9471 WesternBaptistHosp, PaducahKY

0179 WestlakeCommunityHosp, MelrosePark

9999 UnknownHospital


23/24

PRIVILEGED AND CONFIDENTIAL INFORMATIONUNDER THE EMS ACT AND MEDICAL STUDIES ACT

None

No Units Available

High Call Volume

Language Barrier

Location(Inability to Obtain)

Technical Failure(Computer, Phone etc.)

Scene Safety(Not Secure for EMS)

Caller (Uncooperative)

Other

EMS Provider

PERFORMED BY

Patient

Unknown

N/A

Oth HealthcareProvider

LawEnforcement

Lay Person

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

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0

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0

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8

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0

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5

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7

8

9

0

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7

8

9

0

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8

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0

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0

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9

0

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9

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0

1

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6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

AGENCY NO. INCIDENT NUMBERResponse

Downgrade fro

Upgrade to L

No Lights & S

INC. ONSET PSAP CALL UNIT NOTIFIED UNIT ARRIVED BACK IN SRVCLEFT SCENE ARRIVED DEST.

1

2

3

4

5

0

1

2

3

4

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8

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0

1

2

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0

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6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

0

2

:H MH M :H MH M :H MH M :H MH M :H MH M :H MH MUNIT ENROUTE AT PT.

:H MH M :H MH M :H MH M :H MH MBACK AT HOME

1

2

3

4

5

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

0

2

1

2

3

4

5

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

0

2

1

2

3

4

5

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

0

2

1

2

3

4

5

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

0

2

Allergic Reaction

Blood Glucose

Chest Pain (Non-trauma)

Cold Exposure

Altered LOC (non-trauma)

Eye Symp. (non-trauma)

Convulsions/Seizures

Non Traumatic Headache

Cardiac Symp. (atypical pain)

Heat Exposure

Hemorrhage

Infect. Diseases Requiring Isolation

Hazmat Exposure

Medical Device Failure

None

Single

Home/Residence

Street or Highway

Mine or Quarry

DO

NOTMARKINTHISAREA

2010

EMSDataSystems,Inc.

SCANNER COPY Revised 04/Illinois Department of Health

Bleeding

Breathing Problem

Change inResponsiveness

Device/EquipmentProblem

Choking

Death

Diarrhea

Drainage/Discharge

Fever

Malaise

Mass/Lesion

Mental/Psych

Nausea/Vomiting

Pain

Palpitations

Rash/Itching

Swelling

Transport Only

Weakness

Wound

SYMPTOMS (PRIMARY & OTHER)

Lights and S

Construction

PTS OCCUPATIONAL INDUSTRY

Fracture/Dislocation

Penetrating Extremity

Amputation Digits

Amputation Other

Suspected Internal Injury

MulitipleEMS NotOverwhelmed

P O

P O

P O

P O

P O

P O

P O

P O

P O

P O

P O

P O

P O

P O

None

P O

P O

P O

Abnormal

Abdominal Pain

Patient Safety

Restraints Required

Monitoring Required

Chemical Restraint

3rd Party Assistance/Attendant Reqd

P O

P O

P O

VEH. #

CPR

Extricate/Move

Manual Defib.

AED Defibrillation

Improved

Unchanged

Worse

Unknown

N/A

OUTCOME

CHIEF COMPLAINT ORGAN SYSTEM

Cardiovascular

CNS/Neuro

Endocrine/Metabolic

GI

Global

Musculoskeletal

OB/Gyn

Psych

Pulmonary

Renal

Skin

Unknown

CHIEF COMPLAINT ANATOMIC LOC

Abdomen

Back

Chest

Extremity-Lower

Extremity-Upper

General

Genitalia

Head

Neck

P O

Mark Reflex EM-277608-1:654321 GS03

HemorrhageControl/Wnd Mgmt

Airway

Abdnl/Chest Thrust

O2

Assessment

DELAYS

Scene

Transport

None

Crowd

Directions

Distance

Diversion

Extric >20

HazMat

Language

Safety

Staff

Traffic

Veh. Crash

Veh. Failure

Weather

Other

Retail Trade

Services

Transportatio& Public UtiliGovernment

Manufacturing

Mining

Finance, Insurance,& Real Estate

Wholesale Tr

Unknown

MulitipleEMSOverwhelmed

S C A N T R O N

CONDITION CODE (Select all that apply)

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

Skin Signs

Vital Signs

Insurance

Medicaid

Medicare

Not Billed(for any reason)

Unknown

PRIMARY METHODOF PAYMENT

Other Govt.

Self Pay

DISPATCH DELAY

SEVERE

Other Trauma

Monitor/Airway

Major Bleeding

Neurologic Distress

Pain (Severe)

Poisons (all routes)

Alcohol Intox./Drug OD

Severe Alcohol Intox.

Back Pain (no trauma, possible cardio/vasc)

Back Pain (no trauma, neuro sympts)

Behav/Psych (Alt. mental status)

Behav/Psych (Threat to self/others)

Special Handling

Ortho. Device Reqd

Positioning Reqd

Seclusion Required

Risk of Falling off Stretcher

Isolation

PRIOR AID

Unknown N/A

DATE

1

2

3

4

5

6

7

8

9

0

1

2

3

0

Oct

an

eb

Mar

pr

ay

un

ul

ug

ep

ov

ec

YRDAYINCIDENT COUNTY(5-digit FIPS Code)

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

INCIDENTZIP CODE

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

Prehospital

Care Report

llinois Departmentof Public Health

YEARDAY

1

2

3

4

5

6

7

8

9

0

1

2

3

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

19

20

PT DATE OF BIRTH

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

UNITS

Y

M

D

H

No

Yes, w/oPre-ArrivalInstructions

Yes, withPre-ArrivalInstructions

Female

AsianNative Hawaiian orOther Pacific Islander

American Indianor Alaska Native

White

Other Race

Unknown

Pregnant? Y

GENDER

African American/Black

Unknown

Unknown

Hispanic/Latino

Not Hispanic/Latino

Unknown

EMD PERFORMED ETHNICTY

RESP MOD

Clean-up

Decontamin

Equip. Failure

Equip. Replns

None

Other

Staff Delay

Vehicle Failu

Documentat

ED Overcrowd

WORK-RELAT

Y N

TURN-AROUND D

SERVICEREQUESTED

Intercept

MCI

Abdominal Pain

Allergies

Animal Bite

Assault

Back Pain

Breathing Problem

Burns

CO Poisoning/Hazmat

Cardiac Arrest

Chest Pain

Choking

Convulsions/Seizure

Diabetic Problem

Drowning

Electrocution

Eye Problem

Fall Victim

Headache

Heart Problems

Heat/Cold Exposure

Hemorrhage/Laceration

Ingestion/Poisoning

Pregnancy/Childbirth

Psychiatric Problem

Sick Person

Stab/Gunshot Wound

Stroke/CVA

Traffic Accident

Traumatic Injury

Unconscious/Fainting

Unk. Prob. (man down)

Industrial Accident/Inaccessible Incident/

Other Entrapments

Transfer/Interfacility/Palliative Care

InterFacilityTransfer

911 Response(Scene)

MedicalTransport

Mutual Aid

Standby

COMPLAINT REPORTED BY DISPATCH (Select one)

INCIDENT LOCATION TYPECREW MEMBER #1 ID CREW MEMBER #2 ID CREW MEMBER #3 IDPT. HOME ZIP CODEAGE

Farm

Trade or Service(Business, Bars,Restaurants, etc.)

Health CFacility(Clinic, Ho

Lake/ROcean

ResidenInstitutio(Nursing Jail/Priso

# OF PTSAT SCENE

Burns

Near Drowning

Eye Injuries

Sexual Assault Injury

Post-Op Proc. Compl.

Preg. Compl./Childbirth/Labor

Sick Person-Fever

Severe Dehydration

Unconscious/Syncope/Dizziness

Major Trauma

WorkersComp.

CMS SERVICE LEVEL

ALS, Level 1

ALS, Level 1 Emergency

ALS, Level 2

Paramed Intercept

Specialty Care Transport

Fixed Wing (Plane)

Rotary Wing (Helio)

BLS

BLS, Emerg. TBD

Male

RACE

Public Building(Schools, Gov. Offices)

Other

Place of Recreationor Sport

Industrial Place& Premises

POSSIBLEINJURY?

Y N

MAJ MIN

MAJ MIN

BLSALS

BLSALS

BLSALS

BLSALS

N/AN/A

UN

UNK

Oct

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Nov

Dec

1

2

3

4

5

6

7

8

9

0


24/24

PROCEDURE COMPLICATION

EsophagealIntubtn-Other

PROCEDURE AUTHORIZATION

On-Line

On-Scene

Protocol (Standing Order)

Written Orders (Pt. Spec.)

Extravasion

NoneAltered MentalStatus

Esophageal Intubtn-Immediately

Apnea

Bleeding

Bradycardia

Diarrhea

REASON FOR CHOOSING DESTINATION

IV

Unknown

Other

Normal Sinus Rhythm

Agonal/Idioventricular

Artifact

Asystole

Atrial Fibrillation/Flutter

Junctional

Sinus Arrhythmia

Sinus Bradycardia

Ventricular Fibrillation

Ventricular Tachycardia

V Block

1st Degree

2nd Degree-Type 1

2nd Degree-Type 2

3rd Degree

2 Lead ECG

Anterior Ischemia

Inferior Ischemia

Lateral Ischemia

Shockable

Non-Shockable

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

PROVIDERS IMPRESSION (Primary and Secondary)

Abdominal Pain/Problems

Airway Obstruction

Allergic Reaction

Altered Level of Consc.

Behavioral/Psych Disorder

Cardiac Arrest

Cardiac Rhythm Disturbance

Chest Pain/Discomfort

Diabetic Sympt. (hypoglycemia)

Bites

Aircraft Related Acc.

Bicycle Accident

Chemical Poisoning

Child Battering

Drowning

Drug Poisoning

Electrocution

Hyperthermia

Hypothermia

Hypovolemia/Shock

Inhalation Injury (toxic gas)

Obvious Death

Poisoning/Drug Ingestion

Pregnancy/OB Delivery

Respiratory Distress

Non-Motorized Ve

Pedestrian Traffic

Radiation Exposu

Rape

Smoke Inhalation

Stabbing/Cutting

Stabbing/Cutting A

Struck by Blunt/Throw

Venom Stings (plants,

Water Transport A

Unknown

ARREST WITNESSED BY

Initiated Chest Comp.

Healthcare Provider

Lay Person

Not Witnessed

AsystoleBradycardia

Normal Sinus Rhy

PEA

Unknown AEDNon-Shockable Rh

Unknown AEDShockable Rhythm

Vent. Fibrillation

Vent. Tachycardia

Other

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

3

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

0

SYSTOLIC DIASTOLIC PULSE

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

0

PULSE OX

1

2

3

4

5

6

7

8

9

0

1

2

3

4

5

6

7

8

9

0

1

2

0

RESPIRATION WEIGHT

MEDICATION GIVEN & ADMINISTERED ROUTE C = Complication (if multiple complications mark only the most serious one)

None

Alt. Mental Status

Apnea

Bleeding

Bradycardia

Diarrhea

Extravasion

Hypertension

Hyperthermia

Hypotension

Hypoxia

Injury

Itching/Urtic

Nausea

Resp. Distres

Tachycardia

Vomiting

Other

P S

P S

P S

P S

P S

P S

P S

P S

P S

No

Yes, Prior to EMS Arrival

Yes, After EMS Arrival

MEDICAL HISTORY OBTAINED FROM

PresumedCardiac

CARDIAC ARREST ETIOLOGY

Resp.

Electro.

Other

1

2

3

4

5

6

7

8

9

0

SEAT ROW

POSITION OF PT.IN VEHICLE

Dash Deformity

DOA Same VehicleEjection

Fire

Rollover/Roof Deformity

Side Post Deformity

VEHICULAR INJURYINDICATORS

USE OFOCCUPANTAFETY EQUIP.

Protective Gear(Non-Clothing)

Other

None

Unknown

No AirbagPresent

1

2

3

4

5

0

Driver

P S

P S

P S

P S

P S

P S

P S

P S

P S

Respiratory Arrest

Seizure

Sex. Assault/Rape

Smoke Inhalation

Stings/Venom. Bites

Stroke/CVA

Syncope/Fainting

Traumatic Injury

Vaginal Hemorrhage

P S

P S

P S

P S

P S

P S

P S

P S

P S

Fire and Flames

Firearm Assault

Firearm (accidental)

Firearm (self-inflicted)

Lightning

Machinery Accident

Mechanical Suffocation

Non-traffic Accident

Traffic Accident

Motorcycle Accident

Motor Vehicle

Space Intrusion& > 1 ft.

Steering WheelDeformity

WindshieldSpider/Star

Middle

Right

Other

Left(non-driver)

Deployed

Front

Side

Other(Knee,Airbelt, etc.)

AIRBAGDEPLOYMENT

RESUSCITATIONATTEMPTED

Not Attempted

Considered Futile

DNR Orders

Signs of Circulation

AttemptedDefibrillation

Ventilation

FIRST MONITORRHYTHM OF TH

PATIENT

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

DESTINATION/TRANSFERRED

TO, CODE

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

DESTINATIONZIP CODE

Patient Refused C

No Treatment Req

No Patient Found

Dead at Scene

Cancelled

Eye Prtctn

Gloves

Level A Suit

Level B Suit

Level C Suit

Mask

PERSONAL PROTECTIVE EQUIPMENT USED

Released

Transferred Care

Treated

(required for non-hospitaldestinations only)

Adenosine

AlbuterolSulf.

Amiodarone

Anti-emetic

Aspirin

Atropine

Benzo. Spray

CaCl2

Dextrose25%

Dextrose50%

Diazepam

Diphenhydr.

Dopamine

Epi (1:1,000)

Epi (1:10,000)

Etomidate

Flumazenil

Furosemide

Glucagon

Hemo.agent

Lidocaine

Mag.Sulfate

Methylpred.

Metoprolol

Midazolam

Morphine Sulfate

Naloxone

Nitroglycerine

Nitrous Oxide

Other Nebulizer

Oxygen

Oxytocin

Procainamide

ANY RETURN OFSPONTANEOUS CIRCULATION

Yes, Prior to ED Arrival Only

Yes, Prior to ED Arrivaland at the ED

No

Trauma

Drowning

Premature VentricularContractions

Smell of Alcoholon Breath

Alcohol/DrugParaphernaliaat Scene

None

Language

Phys. Restrained

Unconscious

None

Impaired

Developmentally

Hearing

Physically

Speech

Unattnded/Unsuprvsd(including minors)

Premature AtrialContractions

Unknown

EMS

Law Enforcement

Private Vehicle

Transported By:

Unknown

Lap Belt

Shoulder BeltChild Restraint

Eye Protection

Helmet

PFD

ED-Unknown Rhythm

Right BundleBranch Block

Paced Rhythm

PEA

Left BundleBranch Block

No AirbagDeployed

Health Care Pers.

Pt. Admits toDrug Use

Pt. Admits toAlcohol Use

ALCOHOL/DRUGUSE INDICATORS

BARRIERS TOPATIENT CARE

Bystndr/Oth. Family Patient None

ProtectiveClothing

CARDIAC ARREST

1

2

3

0

1

2

3

0

1

0

MEDICATION COMPLICATION

INCIDENT/PATIENT DISPOSITION

TRANSPORT MODE FROM SCENE

EMSSYSTEM

lbs

kgs

SupraventricularTachycardia

Torsades De Points

Sinus Tachycardia

Airway (continued)

Respirator Operation

Suctioning

Change Trach. Tube

Combitube

CPAP

Foreign Body Removal

King LT BIAD

Needle Cricothyrotomy

Surgical Cricothyrotomy

EOA/EGTAIntubtn Confirm ETCO2

Intubation Confirm

Esophageal Bulb

Laryngeal Mask BIAD

Nasal Airway

Nasotracheal Intubation

Nebulizer Treatment

Oral Airway

Orotracheal Intubation

PEEP

Rapid Seq. Induction

Ventilator Operation

Ventilator with PEEP

Assessment

Childbirth

Contact Medical Control

CPR-Stop

Decontamination

Defib-Placement

for Monitoring

Extrication

MAST

Orthostatic BP Measure

Pain Measurement

IV

IO IM IH

ET

IV

IH

IV IO

PO IV IM

Definite

None

Possible

Contraindicationsto Thrombolytic Use

N/A

Unknown

THROMBOLYTIC

SCREEN

PO

IV ET IO

IV IO

IV

IV

IV IM

IV IM PO

IV

IV

IV

IO IMIV

IMIV

IV ET IO

IOIMIV

IMIV

IV

IV IM

IV IM IO

IV IM ET

SL

SC

SC

SC

SC

IV

IH

IV IM

IV

IV

IV IM

IV IO

IV IO

Oth PO SL

SC IM IV ET IO IH

= Endotracheal

= Inhalation

= Intramuscular

= Intranasal

ROUTE

ET

IH

IM

IN

Negative

Positive

Non-conclusive

Cincinnati

STROKE SCALE

Scale

Assessment

5

4

3

2

1

EYES

VERBAL(5yrs)

Spont.(