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Medical Incident Report
Use items one through nine to communicate situation to communications/dispatch.
1. CONTACT COMMUNICATIONS/DISPATCH
Ex: “Communications, Div. Alpha. Stand-by for Priority Medical Incident
Report.” (If life threatening request designated
frequency be cleared for emergency traffic.)
2. INCIDENT STATUS: Provide incident summary and command structure
Nature of Injury/Illness
Describe the injury (Ex:
Broken
leg with bleeding)
Incident Name:
Geographic Name +
“Medical”
(Ex: Trout
Meadow Medical)
Incident Commander:
Name of IC
Patient Care:
Name of Care Provider (Ex:
EMT Smith)
3. INITIAL PATIENT ASSESSMENT: Complete this section for each patient. This is only a brief, initial assessment.
Provide additional patient
info after completing this 9 Line Report. See page 100 for detailed Patient
Assessment.
Number of Patients:
Male/Female
Age:
Weight:
Conscious?
YES NO = MEDEVAC!
Breathing?
YES NO = MEDEVAC!
Mechanism of Injury:
What caused the injury?
Lat./Long. (Datum WGS84)
Ex: N 40º 42.45’x W 123º 03.24’
4. SEVERITY OF EMERGENCY, TRANSPORT PRIORITY
TRANSPORT PRIORITY
Ambulance or MEDEVAC
helicopter.
Evacuation need is IMMEDIATE.
Ambulance or consider air transport if at
remote location. Evacuation may be
DELAYED.
Non-Emergency. Evacuation
considered Routine of Convenience.
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