The Ambulance Report form, outlined by the Department of Health & Family Services in the State of Wisconsin, is a comprehensive document designed to record all pertinent details of a patient's condition, treatment, and transport by EMS personnel. This form adheres to administrative rule HFS 110.04(3)(b), ensuring the systematic collection of critical information, which includes incident specifics, patient demographics, clinical assessment, intervention provided, and the transport log, under the confidentiality guidelines of Wis. Stat. 146.82(1). By systematically capturing this data, the form plays a crucial role in patient care continuity, legal documentation, and quality improvement in emergency medical services.
To ensure accurate and thorough documentation of EMS encounters, click on the button below to begin filling out the Ambulance Report form.
In the realm of emergency medical services, the Ambulance Report Form provided by the Department of Health & Family Services for the State of Wisconsin plays a critical role in ensuring the seamless transition of patient care from first responders to hospital personnel. This comprehensive document, designed in accordance with the administrative rule HFS 110.04(3)(b), captures all facets of the patient's condition and the treatment provided at the scene. From the basic details such as the incident address, patient information, and the emergency contact, to more specific data including the response type, vital signs, and medical interventions executed, every piece of information is meticulously recorded. It also accommodates for the documentation of possible complications during transport, the type of destination facility, and the condition of the patient upon arrival. Notably, this form addresses patient confidentiality concerns in compliance with Wis. Stat. 146.82(1), ensuring sensitive information remains protected. Its structured format not only aids first responders in delivering targeted medical care but also facilitates a more informed and prepared reception by the healthcare facility, ultimately enhancing patient outcomes.
DEPARTMENT OF HEALTH & FAMILY SERVICES
AMBULANCEREPORT
STATE OF WISCONSIN
Division of Public Health
Completion of this form meets the requirements of administrative rule HFS 110.04(3)(b).
Adm. Code HFS 110.04(3)(b)
DPH 7119 (Rev. 02/01)
Some client information in this document is confidential under Wis. Stat. 146.82(1).
Date Incident Reported
Service Name and ID No.
RespondingUnit
Station
Patient Care Record / Alarm No.
Mo/Day/Yr
Incident Address / Location
Incident Municipality
Incident County
Destination Address / Facility Name
Destination Municipality
Destination County
R
E
Mileage:(Loaded)
Lights And Siren To Scene:
οN/A
Crash Report No.
S
End
Begin
Total
οNon-Emergent,NoLights or Siren
οInitial Emergent, Downgrade To No Lights and Siren
P
οEmergent,Lights and Siren
οInitialNon-emergent,UpgradeToLightsandSiren
O(UseMilitaryTimes)
N
Pt. Det.
CallRec.
En Route
At Scene
At Pt.
Lv. Scene
At Dest.
In Service
Crew Member Name / License No.
1.
2.
3.
4.
LocationType
οClinic / Medical
οHighway / Street
οIndustrial
οPublic Building
οResidentialInst.
οUnspecified
οEducationalInst.
οHome / Residence
οMine / Quarry
οPublicOutdoors
οRestaurant / Bar
οOther ________
οAirport
οFarm
οHospital
οNursing Home
οRecreational/Sport
οWaterway
Response Type
οMutual Aid
οResponse To Scene
οStandby
οUnknown
οIntercept
οScheduledInterfacilityTransfer
οUnscheduledInterfacilityTransfer
Patient Last Name / First / M.I.
Mailing Address
City
State
Zip Code
Phone (
)
Emergency Contact Name
Address
D
Personal Physician
Date of Birth
Age
Weight
Gender
ο lbs
οMale
οkg
οFemale
M
O
Social Security No. (Optional)
Race
οWhite
οBlack
WorkRelatedInjury
G
οHispanic
οAmericanIndian/AlaskaNative
ο Yes
ο No
οAsian/PacificIslander
οOther
A Employer
H
I
Insurance 1
Group No.
Insured No.
C
Insurance 2 If MVA, Agency
Phone
Medicare
HMO
Medicaid
Signs / Symptoms
οAbdominal Pain
οBack Pain
οBleeding
ο Bloody Stool
ο Diarrhea
ο Headache
ο Paralysis
ο Syncope
ο Weakness
ο BreathingDifficulty
ο Dizziness
ο Hypertension
ο Palpitations
ο Trauma
ο Unknown
ο CardiacArrest
ο Ear Pain
ο Hypothermia
ο Pregnancy / Childbirth
ο Unresp./Unconsciousο Other___________
ο Chest Pain
ο Eye Pain
ο Nausea
ο Respiratory Arrest
ο VaginalBleeding
ο None
ο Choking
ο Fever/Hyperthermia
ο Numbness
ο Seizures / Convulsions
ο Vomiting
Allergies
Patient's Current Medications
LastOral
Dose
Intake
T
Y
Pre-ExistingMedicalCondition--Medical
Cardiac
Other
οAsthma
οCVA / TIA
οHypotension
οAngina
οMyocardial Infarction
οDevelopmental Delay / MRοOther _______
οBleedingDisorders
οDiabetes
οSeizures / Convulsions
ο Arrhythmia
οCardiac Surgery
ο Psychiatric
οNone
οCancer
________
οGastrointestinal
οTuberculosis
οCongenital
οSubstance Abuse
οChronic Renal Failure
οHeadaches
οCongestiveHeartFailure
οTracheostomy
οChronic Resp. Failure
οHepatitis
οHypertension
Vitals
οVital Continued with Advanced Skills
MentalStatus/Behavior
Eyes
BreathSounds
Pulse
Resp.
Levelof
οNormal
οPERRL
Clear
L
Time
BP
Rate
Qual.
/ SPO2
Resp.Effort
Consciousness
οAcuteConfusion
Reactive
Wet
1
Normal
οUsually Confused
Nonreactive
Decreased
2
Labored
A - Alert______
οIncoherent
Constricted
Wheeze
οReg
3
Shallow
V - Verbal
οIntermittentConsciousness
Dilated
Absent
4
P - Pain
οCombative
Blind
A
οIrr
5
Assisted
U - Unresp
Cataracts
ο
Stridor
Glaucoma
Skin
Moisture
Color
Pain Provoke:________________________
Temp
οNormal οNormal
Quality
Radiate
Severity Time(Onset)
ο Dry
οCyanotic
Sharp
No
(1-10)
0-15Min
οCool/Cold
ο Moist
οPale-Ashen
Dull
Yes
_____
15-60 Min
οWarm/Hot
οDiaph
οCherry
Cramp
1-12 Hr
οFlushed
Crushing
12-24 Hr
CapillaryRefill
Reg
οJaundice
Constant
Other:____
οDelayed
C CPR Provider: οBystander οFirst Responder Unit οEMS Unit οUnkn
Defib Provider: οPADοFirst Responder Unit: ________οEMS Unit: ________
Discontinue ____________ Witnessed Arrest οYes οNo
R CPR Start Time _______
Time _________
page 2
Physical Examination
SI Injury / Pain Location
CHead / Face
LNeck
EChest / Axilla
AX Abdomen
MBack / Flank
N Pelvis / Hip
L Arm
U
J
R Arm
L Leg
R Leg
/Abrasion
Swe
Pain
Dis
GunshotLacerationPunctureSoft
lling
B
Burn
______________
(No
Trauma)
/Stab
FX
issue
lunt
/
οN/A Glasgow Coma Scale
A.
Eye Opening
SceneEnroute
Spontaneous
Tovoice
To pain
None
B.
VerbalResponse
Oriented
Confused
Inappropriatewords
IncomprehensibleWords
C.
MotorResponse
Obeys commands
6
Purposefulmovement
Withdrawstopain
Flexiontopain
Extensiontopain
A. + B. + C. =
____
N/A
MotorVehicleCrash
Type
ExteriorDamageοN/A
InteriorDamage οN/A
Restraints
SafetyEquipment
ο Car
ο Motorcycle
Obs
Rprt
Airbag
οFloat. Dev.
οTruckο ATV
ο Minor
οSpideredWindow
earR
ο Van ο Snowmobile
οModerate
οSt. Wh. Bent
LapBelt
οHelmet
ο Semi οWatercraft
ο Major
οCompart.Intrusion
ShoulderBelt
ο Eye Prot.
ο Bus
οAircraft
οRollover
οPatient Ejected
ChildSeat
οProt.Clothing
C P = Patient Location in Vehicle
X = Location of Damage to Vehicle
CauseofInjury
οN/A οChemical Exposure
οExcessive Heat
οLightning
ο Physical Assault
οStings (Plant / Animal)
οAircraftRelated
οChildBatteringSuspected
ο Fall
ο Machinery Injury
οPoison, Not Drugs
οWaterTransportIncident
οDrowning
οFire / Flames
οMechanicalSuffocation
οRadiationExposure
οAthletic Event
οDrugIngestion
οFirearmSelf-Inflicted
οMotor Vehicle (Non-Traff.)
οSexual Assault
οOther___________
ο Bicycle Crash
οElectrocution(Non-Light.)
οFirearm Accidental
οMotor Vehicle (Traffic)
οSmokeInhalation
ο Bite
οExcessive Cold
οFirearm Assault
οPedestrianTraffic
οStabbing
ProviderImpression If more than one impression is checked, Circle Primary One
οHypothermia
οRespiratory Arrest
οSyncope / Fainting
οHypovolemia / Shock
οRespiratory Distress
οTraumatic Injury
οAbd. Pn. / Problems
οCardiac Arrest
οElectrocution
οIntoxicationSuspected/
οSeizure
οVaginalHemorrhage
οAirway Obstruction οCardiac Rhythm. Disturb.
οGI Bleed
AlcoholIngestion
Sexual Assault / Rape
Unknown
οAllergic Reaction
οChest Pn. Discomfort
οHeadache
οObviousDeath
οToxicInhalation
ο Other___________
οAlteredL.O.C.
οPoison / Drug Ingestion
οStings / Bites
οBehavioral / Psych
οDiabetic Symptoms
οHyperthermia / Fever
οPregnancy / Ob Delivery
οStroke / CVA / TIA
Chief Complaint / Mechanism of Injury:
Time of Onset:
ProcedureorTreatment
EMT
οAssistedVentilation
οBackboard
Comments:
οBleedingControl
οBurn Care
ο CPR
οCervicalImmobilization
οDNR Protocol
οGlucoseAdministration
οNasopharyngeal Airway
οObstetric Care / Delivery
οOropharyngeal Airway
οO2 By Mask ______ liters
οO2 By Cannula ______ liters
ο Physical Exam
οRadio / Phone Report
οSplint of Extremity
οTractionSplint
οVital Signs
οOTHER:________________
If an advanced skill is performed,completeformDPH7300
IncidentDisposition
LightsAndSirenDuringTransport:
οTreated / Transported by EMS
DestinationType
- AND - DestinationDetermination
οTreated/TransferredCare
οNo Treat. Needed
οEmergent, LightsandSiren
οClosest Facility
οTo Aero-Medical Unit
οPolice / Jail
οDiversion
οTo ALS Unit
οDead at Scene
οMedical Office / Clinic
οEMT Choice
οTo BLS Unit
οSkilled Nursing Facil.
οLaw Enforce. Choice
οTo Law Enforcement
οCancelled
PatientTransported
OtherServicesonScene
οHospital Direct Admit
οManaged Care
οProne
οLawEnforcement______
οHospital ED
οOn Line Med. Direction
οTreated / No Transport
οSupine
οFire _______
EL
ο Morgue
οPatient / Family Choice
οTreat. / Trans. by Priv. Veh.
οSitting
ο Other
οPatient / Phys. Choice
οTreat. / Trans. by Other Means
οNo Patient Found
οPatientRestrained
οProtocol
οTreated and Released
οHead Elevated
ο Physician
οSpecialty Center
Patient Refused Care
οFeetElevated
οFirstResponder_______
οIn_____LateralPosition οNurse / PhysicianAssistant
ArrivalStatusοN/A
PPE Used οN/A
Facility Notified By
DifficultiesEncountered
Time Report Received: By:
οUnchanged
οGloves
οRadio
οDispatch οOther _____
Report Given To: ______________________________________
οBetter
ο Gown
οPhone
οExtrication
οWorse
οGoggles
οUnable*
οHazardousMaterial
EMT Signature
οDOA
ο Mask
οNo Need*
οLanguageBarrier
οOther________
οDirect
οRoad
οEKG Telemetry
οUnsafe Scene
*Explain________________
οVehicle Problems
οWeather
Once an ambulance service has responded to and managed a situation requiring their intervention, the next step involves accurately completing an Ambulance Report form. This documentation is necessary to ensure that all aspects of the patient care and service delivery are recorded in a structured and reliable format, complying with regulations. The data collected serves multiple purposes, including reviewing the care provided, facilitating billing processes, and contributing to healthcare statistics and research. Accurately filling in this form is crucial for maintaining the integrity of patient records and ensuring continuity of care.
What is the purpose of filling out an Ambulance Report Form?
The primary purpose of completing an Ambulance Report Form is to document all the critical details regarding the patient's condition, the care provided by the ambulance crew, and the circumstances surrounding the incident. This form fulfills the requirements specified in the administrative rule HFS 110.04(3)(b) and ensures that all the necessary information is communicated to the healthcare professionals who will continue patient care. It also serves as an essential record for legal, billing, and quality improvement purposes.
Is patient consent required to fill out an Ambulance Report Form?
Generally, patient consent is implied for the collection and use of medical information in emergency situations, under the assumption that the treatment and transport are in the person’s best interest. However, patient information documented in the Ambulance Report Form is considered confidential under Wis. Stat. 146.82(1). Any use or disclosure of this information outside of direct patient care or without explicit patient consent could be a violation of patient privacy laws.
What information is collected in this form?
The Ambulance Report Form collects a wide array of information, important for understanding the incident and the patient’s condition. This includes but is not limited to, the incident's date and location; the patient's personal details, medical history, and current medical condition; staff involved; and the care provided during the transport. Details such as the use of lights and sirens, mileage covered, and the eventual destination are also recorded for operational and billing purposes.
Who fills out the Ambulance Report Form?
The form is typically filled out by the ambulance crew attending to the patient. This includes emergency medical technicians (EMTs), paramedics, and sometimes, if present, other first responders or medical professionals who assisted at the scene or during the transport. The crew is responsible for documenting accurate and timely information to ensure continuity of care and compliance with legal and regulatory requirements.
How is the filled-out form used after the incident?
After the incident, the completed Ambulance Report Form is used by hospital staff or healthcare providers to understand the pre-hospital intervention and to continue appropriate medical treatment. It may also be reviewed by insurance companies for billing purposes, law enforcement if necessary, and the emergency services department for quality control, training, and accreditation. In some cases, parts of the report may be shared with the patient or their legal representatives upon request.
Can changes be made to the form after it's been submitted?
While the initial submission should be as accurate and complete as possible, if errors are discovered or if critical information was omitted, amendments can usually be made in accordance with the department's policies and local regulations. It is important that any changes maintain the integrity of the original document and are clearly noted as amendments, including who made the change and when, to ensure transparency and accountability.
Filling out an Ambulance Report form is a critical task that can easily be mishandled if not given the necessary attention to detail. One common mistake involves inaccuracies in completing the patient's personal information, such as misspelling their name or entering an incorrect Social Security number. This could not only jeopardize the patient’s privacy but also affect billing processes and potentially cause confusion in the patient's medical record.
Another error frequently observed is failing to accurately record the incident’s specifics, including the exact location and time of the incident. Precise documentation is essential for legal purposes and for understanding the context of the emergency. Ambulance reports serve as a vital record that may be reviewed in court cases or by insurance companies, making accuracy and completeness paramount.
Additionally, when documenting the patient’s medical condition, it is critical to correctly identify and describe the symptoms and signs observed. A common misstep is the incomplete recording of vital signs or symptomatic descriptions, which are crucial for ensuring continuity of care. These details help subsequent healthcare providers make informed decisions about further tests and treatments.
Selecting the incorrect response code for the lights and siren use is yet another mistake. The options ranging from 'Non-Emergent, No Lights or Siren' to 'Emergent, Lights and Siren' provide essential information about the urgency of the situation and how it was handled. Misclassification can affect the evaluation of the response and the urgency of the situation.
Errors in noting the patient's current medications and allergies are not uncommon. This information is vital for preventing adverse drug interactions and allergic reactions, particularly in emergency settings where time is of the essence. Failing to document this information comprehensively can lead to potentially dangerous treatment errors.
The completion of the procedure or treatment section also often contains inaccuracies. It is imperative to document every intervention performed and its timing accurately. This not only helps in the billing process but also ensures that there is a clear medical record of the care provided during the emergency.
Last but not least, improperly documenting the incident disposition, including the patient's destination and the use of lights and siren during transport, can lead to regulatory and compliance issues. This section of the form communicates the outcome of the ambulance service, making its precise completion a necessity for a variety of logistical and legal reasons.
When an ambulance crew responds to an emergency, they utilize several forms and documents alongside the Ambulance Report form to ensure a comprehensive account of the incident and patient care provided. These documents play a crucial role in patient care continuity, legal compliance, and billing processes.
Together with the Ambulance Report form, these documents ensure a well-documented, efficient, and legally compliant response to emergencies. They serve as critical tools for healthcare providers, insurers, and legal authorities to understand the circumstances of an emergency call, the decision-making process of the crew, and the care provided to the patient.
The Ambulance Report form shares similarities with the Police Incident Report. Both documents are essential for recording specific details about an incident as soon as it occurs. A Police Incident Report, much like the Ambulance Report, collects data on the location, time, and parties involved in an incident. Highlighting facts such as the incident's nature, involved individuals, and witness statements, it parallels the Ambulance Report's emphasis on detail and accuracy to ensure a comprehensive record. These reports both serve as critical pieces of evidence and are instrumental for further investigation or legal proceedings.
Similar to the Ambulance Report, a Patient Care Report (PCR) is utilized by emergency medical services (EMS) to document the medical care and condition of a patient from the point of contact until the handover at a medical facility. Both documents include detailed information about the patient's initial condition, the interventions or treatments provided, and the patient's response to these interventions. The inclusion of vitals, administered medications, and observed symptoms in a PCR mirrors the detailed patient data captured in an Ambulance Report, highlighting their roles in ensuring continuity and quality of patient care.
The Medical History Form is another document that bears resemblance to the Ambulance Report. This form is frequently used by healthcare providers to gather comprehensive health information from patients, including past medical history, medications, allergies, and previous surgeries or treatments. Like the Ambulance Report, it aims to collect pertinent health information that can influence patient care. While the Medical History Form provides a broader view of the patient's health over time, the Ambulance Report focuses on the patient's immediate condition and the emergency care provided. Both facilitate tailored and informed healthcare delivery.
An Emergency Room (ER) Admission Form is similar to the Ambulance Report as it is used to document the essential information of a patient upon their arrival at an emergency department. This form records the patient's presenting problem, vital signs, and preliminary diagnosis, similar to how the Ambulance Report outlines the immediate assessments and interventions at the scene or en route to the hospital. The ER Admission Form extends the continuum of care by leveraging the preliminary data from the Ambulance Report to expedite critical, life-saving treatments in the ER setting.
Completing the Ambulance Report form is an essential part of documenting medical responses and treatments provided during an emergency service call. The details captured in this form play a critical role in ensuring continuity of care, meeting legal and administrative requirements, and facilitating any necessary follow-up actions. To optimize the utility and accuracy of this documentation, there are several dos and don'ts that should be considered:
In conclusion, the Ambulance Report form is a vital document that requires careful and precise completion. Adhering to these dos and don'ts can greatly aid in ensuring that the form fulfills its intended purposes of documentation, communication, and legal compliance.
When it comes to understanding ambulance report forms, like the one used in Wisconsin, there are common misconceptions that can lead to confusion for patients, their families, and sometimes even healthcare professionals. Clearing up these misunderstandings is vital for a better grasp of how emergency medical information is recorded and used.
Understanding these aspects of the ambulance report form can help demystify the process and highlight the importance of thorough documentation in emergency medical care. It’s about much more than just paperwork; it’s a crucial part of a patient's medical journey.
Filling out an Ambulance Report form accurately and completely is crucial, as this document plays a vital role in ensuring that patients receive the most appropriate care. Here are key takeaways to consider:
By keeping these takeaways in mind, healthcare professionals and emergency responders can ensure they provide the best possible patient care informed by accurate and comprehensive data from the Ambulance Report form.
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