HTML Preview Blank Medical Incident Report page number 1.
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
SEVERITY
TRANSPORT PRIORITY
URGENT-RED Life threatening injury or
illness. Ex:
Unconscious, difficulty breathing, bleeding severely, 2º-3º
burns more than 4 palm
sizes, heat stroke, disoriented.
Ambulance or MEDEVAC
helicopter.
Evacuation need is IMMEDIATE.
PRIORITY-YELLOW Serious injury or
illness. Ex:
Significant trauma, not able to walk, 2º-3º burns not more than
1-2 palm sizes
Ambulance or consider air transport if at
remote location. Evacuation may be
DELAYED.
ROUTINE-GREEN
Not a life threatening injury or illness. Ex:
Sprains, strains,
minor heat-related illness
Non-Emergency. Evacuation
considered Routine of Convenience.