Penn State Emergency Medical Services
Penn State EMS Standard Operating Procedures and Constitution
University Ambulance Service
Centre County Company 20
Procedures Manual
Penn State EMS Standard Operating Procedures and Constitution
OFFICE OF EMERGENCY MEDICAL SERVICES
FORMS USAGE
CONTENTS
Daily Ambulance Check
Daily Check Sheet
Daily Trip Log
PA State Trip Form
QA Trip Sheet Review - Medical
QA Trip Sheet Review - Trauma
Special Events Incident Form
Special Events Incident Log
Special Events Request Form
Third Person Evaluation Form
Trainee Call Evaluation Form
Vehicle Accident Report
Report of Injuries by Deadly Weapon or Criminal Act
Oxygen Survey Report
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DAILY AMBULANCE CHECK FORM
Purpose:
This form is completed by EMS crew members during daily ambulance inventory.
Where to Obtain Form:
Forms are located in the clipboard located in the cab of the ambulance. Additional
forms may be found in the EMS Supervisor's office.
Number of copies and Distribution:
1 Copy (original)
Original - EMS Supervisor
Instructions:
Date: Enter today's date and circle the appropriate day.
UAS EMT #: Enter you current Co. 20 Number.
Ambulance Interior/Floor is clean: Check if ambulance is clean both inside as well
as outside.
General Equipment:
Engine:
After inspecting the following fluids, check off in the space provided. Battery water,
Oil, Radiator Fluid, Washer Fluid.
Cab:
Mileage: Write in current mileage from Odometer.
Fuel: Write in current fuel level
Check the following and mark off on form: Wipers, Washers, Horn/Air Horn/
PA/ Siren, Radios (University and Centre County), Med Portable with Holster,
Air Conditioner/ Heater, Lights (Dash, Dome, Spotlight, Turn Signal Indicator,
High Beam Indicator), 2 Helmets, 2 Turnout Coats, Map Books/Rolled Maps,
Spare Forms (Patient Work., Trip, Insurance Release, MAST, Rig Check).
Exterior Lighting:
Turn on and visibly inspect the following exterior emergency/warning lights:
Headlights (Low/High), Running/Box Lights, Turn Signals/4-ways, Brake Lights,
Back-up Lights, Light Bar (each bulb), Rear Light Bar (2 bulbs), Emergency Flashers
(Box/Grille), Scene Lights (Right, Left, Rear).
Exterior Compartments:
Inventory the following items located in the indicated exterior ambulance
compartments: (RR) Coat/Helmet/Jump Kit, (R) Long Board with CID, Short
Board, Orthopedic Stretcher, (LR) KED / Adult/Ped HARE Traction, Jumper Cables,
(LM) Tools / Flares / Spare 02, 2 Flashlights, Oil, Fire Extinguisher - write date of
last fire extinguisher inspection, (LF) Reeves Stretcher / Halligan Tool, Portable 02
cylinder - write in 02 tank pressure, Nasal Cannulae / Simple Mask / Partial
Rebreather.
Patient Compartment:
Fixtures: Turn on and check operation of the following fixtures: Compartment
Lights, Attendant Lights, Ventilator, Climate Control, Suction, Code Lights,
buzzer, On-Board 02 - write in 02 tank line pressure.
Equipment: Inventory and mark off the following miscellaneous equipment:
Suction Catheter, Small Emesis Basin / Bite Stick / Pen Light, Fire Extinguisher -
write in date of last fire extinguisher inspection, 2 Jump Suits, 1 Pillow, Air Splints,
Folding Cot / Stair Chair, Backboard, Padded Board / Ladder Splints, MAST
(adult/Ped), Demand Valve Assembly (in ceiling), Portable Suction (water, catheter),
Main Jump Kit (BP cuff, BVM, Airways, Scissors, Penlight, Tape, Cravats, Dressings,
Occlusive, Band-aids, Butterfly Closures, Ice/Heat Packs, Glucose, Poison Antidote,
Gloves.
Interior Cabinets: Inventory and check off all of the following equipment from the
interior ambulance cabinets: Oxygen/ Suction Supplies: Nasal Cannulae, Non-
Rebreather, Suction Tubing/Catheters, oral airways, nasal airways, KY jelly, BVM
with connective hose, BP cuffs (adult/ped), Insta-Glucose, Rubber Gloves, Poison
Antidote Kit, Glucose, Saline/Sterile Water, Linens/Towels/Blankets, Emesis
Basins (2), Trauma Dressings, Bandages, Tape, Patient Restraints, Ice/Heat Packs,
CID, Infectious Disease Kit, OB Kit/Pads, Sand Bags, Straps, Foil, Sterile Sheets,
Stiffneck Collars (5 sizes).
Maintenance/Supplies/Comments: Document any findings of maintenance that
may be necessary of either equipment or ambulance operations, supplies that can
not immediately be restocked, or additional problems/comments.
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DAILY CHECK SHEET
Purpose:
This form is completed by UAS night crews upon completion of all daily duties.
Where to Obtain Form: Check forms may be found in the daily log binder located on
the desk in UAS duty room, room 21 Ritenour Buildinq.
Number of Copies and Distribution:
1 copy (original)
original - daily log binder
Instructions:
Rig Check: Check off the space provided if the daily ambulance inspection was
completed.
Security Check: Place a check mark on the line if duty crew performed the nightly
security check of Ritenour Building. Document what time the security check was
completed. Keep track of all unlocked doors and place a list of these doors in the
EMS Supervisor's mailbox located at the front desk of Ritenour Building.
Crutches: Check off if any crutches were repaired or put together. Indicated the
number done in the space provided.
QA: Cross off on the line provided if any QA sheets were completed during the
shift. Indicate the number done where indicated.
Duty and Break Rooms Clean: Place a check mark if the duty room and break room
are neat.
Radios: Mark off if all radios, pagers, keys, radio cases, and belt loops are where they
are stored when not in use.
Comments: In this area document any unusual findings or events, any offices
found unlocked during security check, any missing equipment, number of
crutches and QA completed, or reasons why any of the above were unable to be
completed.
Crew: On the line provided, write in all duty crew members and trainees.
Date: Indicate the date of the shift during which the form was filled out.
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DAILY TRIP LOG
Purpose:
This form is completed by crew members upon completion of an ambulance call
and trip form.
Where to Obtain Form:
Located in the call log binder at the front desk of Ritenour Building.
Number of Copies and Distribution:
1 Copy (original)
Original - Call Log Binder
Instructions:
UAS TRIP Number: Assign the ambulance call a number which represents the
sequential order of UAS calls responded to for the current year.
Dispatch Date: Indicate the date in which the call was dispatched. Calls dispatched
before midnight are dated on this form according to the time of dispatch.
Dispatch Time: Document the time of dispatch of the ambulance trip according to
Centre County Dispatch Center.
Pt. Last Name, First Initial: Write in the last name and first initial of the patient, or
"npt" if no patient was transported. Information is obtained from the "patient
information" section on the PA State Trip Form.
Call Type: Indicate the type of ambulance call dispatched to. IE: Alcohol
Overdose, Seizure, Fracture. Call Location: Indicated the location of the ambulance
call such as specific residence hall, roadway, athletic room, etc.
X-port to: Document the facility to which the patient was transported and patient
care transferred.
Dispatch By: Write the abbreviation for the dispatch center through which the call
was received, either Center County Dispatch or University Dispatch.
Cover For: If the ambulance call was turned over from another ambulance service
indicated which service was first dispatched.
ALS Y/N: If the call involved Advanced Life Support provided by Medic 24
indicate so by writing a "Y", otherwise write "N".
AR Y/N: If the call was alcohol related indicate "Y"; if alcohol was not involved in
the incident, write "N".
E or N Disp.: Indicate whether the call was dispatched emergency or non-emergency
by writing either "E" for emergency or "N" for non-emergency.
Stdnt Y/N: Indicate whether the patient was a student on
non-student by writing either "Y" for student or "N" for non-student. Crew:
Document the responding ambulance crew by company 20 number and last name.
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PA STATE TRIP FORM
Purpose:
This form is completed by Pennsylvania state certified Emergency Medical
Technicians upon completion of an ambulance call.
Where to Obtain Form:
Forms are located in the clipboard found in the ambulance cab; additional forms are
kept in the UAS EMS Supervisor's office.
Number of Copies and Distribution:
3 copies (original and 2 carbon copies
Original - Seven Mountains EMS Council
Hospital Copy (yellow) - Receiving Hospital/Facility
Service Copy (pink) - UAS EMS Supervisor
Instructions: Front page of form:
Affiliate/Unit Number: Write in the affiliate number of UAS (14011) and the
responding unit number (51) and code the appropriate dots.
Incident Location MCD Code: Write in and code the number which represents the
incident location. This number can be found attached to the clipboard located in the
cab of the ambulance and reflects the township/borough in which the incident
occurred.
Month: Fill in the correct space for the month in which the call occurred.
Day: Write in and darken the corresponding spaces for the day of the ambulance
call.
Year: Write in and darken the correct year for the trip.
Attendant #1: Write in the last name of the ambulance attendant in charge of
patient care. This is the attendant who wrote the narrative on the reverse side of
the trip form. Darken the circle corresponding to the proper certification level: H -
Health Professional, P Paramedic, E - EMT, F - First Responder, A - Attendant, D -
Driver, O - Other. In the following boxes, write in and code the numbers for the
certification number as registered with the state of Pennsylvania, i.e. you EMT or
first responder number. If the certification level is marked "O", leave the number
columns blank.
Attendant #2: Write in the last name of the ambulance attendant who drove the
ambulance from scene to the receiving hospital. Darken the circle corresponding to
the individual's certification level as outlined above as for "Attendant #1." Write
in and code the certification number as outlined above.
Attendant #3/#4: Write in the last name of any additional attendants who
may have been on the call. This includes trainees, additional EMTs needed for
extenuating circumstances, etc. Again, Code the certification level and
certification number of these individuals.
Response/Transport Mode: To Scene: Code the mode used in the response to scene.
Instructions: Back page of form:
Service Name: Write in the name of the responding ambulance service -
University Ambulance Service.
Service #: Write in the affiliate number for the responding ambulance service -
14011-51.
Incident #: Write in the incident number received from Centre County Dispatch.
Today's Date: In the boxes provided, write in the date of the ambulance call
according to month, day, and year. Incident Location: Write in the location of
the ambulance call, according to dispatch and where the patient was found.
Patient Information: Document any available patient information in the correct
areas. Such information can be obtained directly from the patient, from
bystanders/family members, or from the hospital cover sheet obtained from
emergency/outpatient reception area behind Fast-Track of Centre Community
Hospital. Patient Last Name: Write the last name of the patient in the space
provided.- First: Write in the patient's first name. M.I. Enter the patient
middle initial if available. Phone: Enter phone number of the patient. Age:
Indicate the age of the patient. Date of Birth: According to month, day, year, write in
the patient's date of birth in boxes provided. Sex: Indicate the gender of the
patient. Street Address: Document the street address of the patient. Social Security
Number: In the boxes provided, write in the patient's social security number.
Membership: Leave blank, UAS does not sell memberships. City: Write in the city
the patient currently resides in. State: Write in the abbreviation of the patient's
state of residence. Zip Code: Indicate the patients current zip code. Private
Physician: If the patient has a private physician that should be contacted, indicate
the physician's name.
The following sections should be left blank: Bill to (Company or Name), Phone,
Address, Street, City, State, Zip Code.
If at all possible, document any available insurance information. The following are
categories as seen on the trip form: Insurance Code #, Medicaid #, Medicare #,
Group Insurance #, Other Insurance #. This information will be listed on the
cover sheet obtained at the hospital.
Mileage: Document mileage of the responding unit. Mileage should be written
down for travel out from the station, on scene, at destination (i.e. hospital), and
mileage back in quarters. If the call is a refusal or fire standby, etc., the destination
mileage should be left blank.
Chief Complaint: Document the chief complaint of the patient. This is subjective
to what the patient states. In the event of unconscious patient the chief complaint
should be documented as "None Voiced".
Current Medications: Write in all known medications the patient currently takes.
If unable to determine this data, or in the event that the patient is not taking any
medication, darken the circle marked "None Known."
Allergies (Meds): Indicate any medications that the patient has a known allergy to
taking. If the patient has no known allergies, darken the circle marked "None
Known."
Past Medical History: Document any past medical problems that the patient has
had by darkening the circles corresponding to the medical history. Categories
listed on the form are: MI (myocardial infarction), CHF (congestive heart
failure), COPD (chronic obstructive pulmonary disease), High Blood Pressure,
Diabetes, Cancer, None Known, and Other. If the patient has a condition not
specifically listed, mark "Other" and write the medical condition in the space
provided.
Narrative: Document in narrative format the events of the ambulance call. There
is no exact format for this, however, there are some guidelines as to what
information need be included. Document disPatch information such as, response
mode, dispatching center, any other responding units, location, etc. Include patient
chief complaint, level of consciousness, gender, age, and position patient was found
once the unit arrived on scene. Describe the situation leading up to the incident
(history of present illness) as described by the patient including any symptoms
expressed by the patient or bystanders. Document the physical exam of the
patient. This varies from patient to patient and is determined by the injury type.
Include ALL physical findings, bruises, coloring, patient appearance, and signs.
Record all vital signs taken during the call. Remember signs such as pupil
size/reaction, lung sounds, etc. Restate the past medical history. medications,
and known drug allergies of the patient. Document completely all treatments
administered to the patient. Include any splinting, bandaging, oxygen therapy,
spinal immobilization, etc. performed. Also include patient reactions to treatments.
For example, did administering oxygen improve patient respiratory efforts?
Document information regarding patient transport from scene to the receiving
facility. Include and further treatments or vital signs obtained while enroute,
position in which the patient was transported, and any unusual incidents (i.e.
patient went combative) which may have occurred during transport. Document
facility/unit which received patient transfer of care. Document number of gloves
used during the call, as per UHS infection control policy. Any extenuating or
unusual circumstance should be documented in the narrative. Such
circumstances might include extended onscene times due to circumstances out of
crew members control. Attendant #1, the crew member who wrote the narrative
must sign after the last line of narrative documentation. Darken in the circle
corresponding to narrative 1 of and write in the number of pages of completed
narrative.
Time: Document times for all patient interventions such as primary/secondary
assessment, vital signs, and other relevant treatments. These times are obtained on
scene by the attending crew members, not by Centre County Dispatch Center.
P: This column is for recording any obtained pulse rates.
R: Write any respiratory rates recorded in this column.
B/P: Document all blood pressure readings taken during the ambulance call. The
systolic number goes in the top triangle if the column, and the diastolic reading goes
in the lower triangle.
Rhythm: Describe the rhythm of the recorded vital signs as outlined by PA State
EMT standards (i.e. strong, regular; strong, irregular).
Treatment: Document a listing of treatments provided during the call.
Provider ID#: Write the PA certification number of the attendant who performed
the listed treatment.
Response/Comments: Describe any patient responses to treatment or any further
comments concerning the intervention listed.
Signature of Person Receiving Patient Time: This line is to be signed and time
received recorded by a staff member at the receiving facility to prove that the patient
was not abandoned at the facility.
Command Physician ID#: This section is intended to be signed by the command
physician. Often this signature is unable to be obtained, and thus, left blank.
Crew Signatures: A signature form every crew member involved in the ambulance
call needs to be included in the proper space. Each row is entitled according to
attendant number (A#1 through A#4).
Release of Patient Insurance Information: This section is not used by UAS crew
members, therefore, do not fill out this section.
Patient Refusal of Services: This section must be signed and completed in the event
of a patient who refuses treatment and/or transport. The patient full name should
be printed on the line after the statement "This is to certify that I,". Darken the
circle(s) corresponding for which the patient is refusing - treatment, transport, or
other. Signature of patient: have the patient sign on the line provided as proof of
refusal. Date: Have the patient date the form after their signature. Have any
witnesses (preferably crew members or other medical staff) sign and date the
refusal in the spaces provided.
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QA TRIP SHEET REVIEW - MEDICAL
Purpose:
This form is completed by on-duty UAS crew members to assure quality assurance
of all completed PA State Trip Forms.
Where to Obtain Form:
Forms are kept in the lower left hand drawer of the desk located in room 21
Ritenour (CO. 20 Duty Room). Additional copies may be photocopied as needed.
Number of Copies and Distribution:
1 copy (original)
(original) - UAS EMS Supervisor
Instructions:
Trip #: Write in the ambulance trip number as listed in the UAS call log book
located at the front desk of Ritenour Building.
Trip Sheet #: Write the number of the PA State Trip Form completed for the
incident. This number can be found on the far right margin of the data collection
side of the PA State Trip Form, midway down the page or in the middle of the
bottom margin of the narrative side of the PA State Trip Form.
Date: Indicate the date of the ambulance call as documented on the PA State Trip
Form.
Crew: In the spaces provided, document all attending UAS crew members by last
name, as seen on the PA State Trip Form.
Administrative:
Response Time: Calculate and document the response time of the responding unit.
This number is calculated by subtracting the "dispatch time" from the "enroute
time" found on the data collection side of the PA State Trip Form.
Scene Time: Calculate and enter the time spent on scene by the responding unit.
This is determined by subtracting the "depart scene" time from the "arrive scene"
time documented on the data collection side of the PA State Trip Form.
MCD: Place and " " sign in the space provided if the responding crew documented
the correct MCD code for the call location as found in the clipboard located in the
ambulance cab. If this code is incorrect, indicate so by placing an "X" in the space
provided.
Pt. Age: Indicate the age of the patient as found on both sides of the completed PA
State Trip Form.
Major:
History:
Chief Complaint: Using the key located at the bottom of the page (X = Deficient, / =
OK, N/A = Not Applicable), indicated whether the chief complaint of the patient
was documented in the "chief complaint" section and narrative of the PA State Trip
Form.
HPI: Indicate whether the history of present illness of the patient was documented
in the narrative of the PA State Trip Form. Indicate so according to the key listed
above.
TX. Prior Arrival: If applicable, mark whether the responding crew documented
any treatments the patient may have received prior to their arrival. This
information can be found in the narrative section of the PA State Trip Form.
Physical Exam:
Vitals: Using the key explained above, mark whether or not the crew correctly
documented all vital signs obtained on the ambulance call. This information is
located on the data collection side, in the narrative section, and in the treatment
section of the PA State Trip Form.
Glasgow: Verify that the attending crew determined and documented the Glasgow
Coma Scale of the patient on the PA State Trip Form data collection side.
Treatment Airway: Indicate if the crew performed and documented the proper
treatment of that patient's airway. This information can be found in the BLS
treatment section, the narrative, and the treatment section of the PA State Trip
Form.
Minor:
PMH: Verify that the UAS attendant documented past medical history of the
patient in the past medical history section and in the narrative of the PA State Trip
Form.
Meds: Mark appropriately if the attending crew correctly documented medications
the patient is currently taking. This information should be documented in the
current medications section and in the narrative section of the PA State Trip Form.
Allergies: Check to see that the documenting crew member indicated any patient
allergies to medications in the allergies (meds) section and the narrative of the PA
State Trip Form.
Weight: Indicated whether or not patient weight was documented/estimated in the
narrative of the PA State Trip Form.
Lung Sounds: Verify if patient lung sounds were indicated to be checked and
the results documented in the narrative and treatment sections of the PA State Trip
Form.
Abdomen: Check to see if assessment of patient abdomen was indicated and what
the result of the assessment was if performed. This should be documented in the
narrative section of the PA State Trip Form.
Oxygen: Verify if appropriate use of oxygen therapy was determined and
documented in the BLS treatment section, the narrative, and the treatment section
of the PA State Trip Form.
Was Tx. Appropriate: Using EMT-Basic standards, indicate if the attending crew
member's treatment was appropriate for the patient condition documented on the
PA State Trip From.
Was IFC Procedure Followed? Check to see if the use of gloves or any additional
infection control equipment was documented in the narrative of the PA State Trip
Form.
EMT Comments: In the space provided, make any further comments or
explanation in reference to any of the above sections.
Medical Director Review/Comments: Pass/Fail: This section is for review of the
Trip Sheet Review Medical form by UAS Supervisor. This individual determines
whether or not the attending crew passed the review of the particular ambulance
call.
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QA TRIP SHEET REVIEW - TRAUMA
Purpose:
This form is completed by all UAS night duty crews to establish quality assurance of
the PA State Trip Forms.
Where to Obtain Form:
Forms are located in the lower left hand drawer of the desk located in room 21
Ritenour Building (EMT Duty Room). Additional copies may be xeroxed when
necessary.
Number of Copies and Distribution:
1 copy (original)
Original - UAS EMS Supervisor
Instructions:
Trip #: Write in the ambulance trip number as listed in the UAS call log book
located at the front desk of Ritenour Building.
Trip Sheet #: Write the number of the PA State Trip Form completed for the
incident. This number can be found on the far right margin of the data collection
side of the PA State Trip Form, midway down the page or in the middle of the
bottom margin of the narrative side of the PA State Trip Form.
Date: Indicate the date of the ambulance call as documented on the PA State Trip
Form.
Crew: In the spaces provided, document all attending UAS crew members by last
name, as seen on the PA State Trip Form.
Administrative:
Response Time: Calculate and document the response time of the responding unit.
This number is calculated by subtracting the "dispatch time" from the "enroute
time" found on the data collection side of the PA State Trip Form.
Scene Time: Calculate and enter the time spent on scene by the responding unit.
This is determined by subtracting the "depart scene" time from the "arrive scene"
time documented on the data collection side of the PA State Trip Form.
MCD: Place a "/" sign in the space provided if the responding crew documented the
correct MCD code for the call location as found in the clipboard located in the
ambulance cab. If this code is incorrect, indicate so by placing an "X" in the space
provided.
Pt. Age: Indicate the age of the patient as found on both sides of the completed PA
State Trip Form.
Major:
History:
Chief Complaint: Using the key located at the bottom of the page (X = Deficient, / =
OK, N/A = Not Applicable), indicated whether the chief complaint of the patient
was documented in the "chief complaint" section and narrative of the PA State Trip
Form.
HPI: Indicate whether the history of present illness of the patient was documented
in the narrative of the PA State Trip Form. Indicate so according to the key listed
above.
TX. Prior Arrival: If applicable, mark whether the responding crew documented
any treatments the patient may have received prior to their arrival. This
information can be found in the narrative section of the PA State Trip Form.
Mechanism Of Injury: Verify that the mechanism of injury of the incident was
documented in the situation of injury section and also in the narrative of the PA
State Trip Form.
Physical Exam:
Vitals: Using the key explained above, mark whether or not the crew correctly
documented all vital signs obtained on the ambulance call. This information is
located on the data collection side, in the narrative section, and in the treatment
section of the PA State Trip Form.
Glasgow: Verify that the attending crew determined and documented the Glasgow
Coma Scale of the patient on the PA State Trip Form data collection side.
Abdomen: Check to see if assessment of patient abdomen was indicated and what
the result of the assessment was if performed. This should be documented in the
narrative section of the PA State Trip Form.
Signs of Trauma: Indicate the appropriate response if the responding crew
documented the physical signs of trauma found during patient physical exam.
Distal Pulses: If the patient injury indicates a need to assure distal pulses, verify
that the attending crew member documented so in the narrative of the PA State
Trip Form.
Treatment
Airway: Indicate if the crew performed and documented the proper treatment of
that patient's airway. This information can be found in the BLS treatment section,
the narrative, and the treatment section of the PA State Trip Form.
Immobilize C-Spine: Verify that the attending crew documented that C-spine
immobilization was performed if patient condition warranted so. This data should
be documented in the BLS treatment section, the narrative, and the treatment
section of the PA State Trip Form.
Control Bleeding: If patient condition indicates any attempt to control bleeding,
check that crew has documented so in the BLS Treatment section, the
narrative, and the treatment section.
Minor:
PMH: Verify that the UAS attendant documented past medical history of the
patient in the past medical history section and in the narrative of the PA State Trip
Form.
Meds: Mark appropriately if the attending crew correctly documented medications
the patient is currently taking. This information should be documented in the
current medications section and in the narrative section of the PA State Trip Form.
Allergies: Check to see that the documenting crew member indicated any patient
allergies to medications in the allergies (meds) section and the narrative of the PA
State Trip Form.
Position Found: Verify that the crew documented in the narrative of the PA State
Trip Form the position in which the patient was found upon crew arrival to scene.
Weight: Indicated whether or not patient weight was documented/estimated in the
narrative of the PA State Trip Form.
Lung Sounds: Verify if patient lung sounds were indicated to be checked and
the results documented in the narrative and treatment sections of the PA State Trip
Form.
Pupils: Mark whether or not the crew determined pupil size and reaction to light in
the narrative section and the treatment section along with vital signs.
Sensation: Indicate that sensations (neuro) were correctly documented in the
narrative and treatment section of the PA State Trip Form.
Oxygen: Verify if appropriate use of oxygen therapy was determined and
documented in the BLS treatment section, the narrative, and the treatment section
of the PA State Trip Form.
Was Tx. Appropriate: Using EMT-Basic standards, indicate if the attending crew
member's treatment was appropriate for the patient condition documented on the
PA State Trip From.
Was IFC Procedure Followed? Check to see if the use of gloves or any additional
infection control equipment was documented in the narrative of the PA State Trip
Form.
EMT Comments: In the space provided, make any further comments or
explanation in reference to any of the above sections.
Medical Director Review/Comments: Pass/Fail: This section is for review of the
Trip Sheet Review Medical form by UAS Supervisor. This individual determines
whether or not the attending crew passed the review of the particular ambulance
call.
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SPECIAL EVENTS INCIDENT FORM
Purpose:
This form is completed by attending UAS crew members following every medical
incident encountered at UAS special events.
Where to Obtain Form:
Forms are located in the special events clipboards found in the special event jump
kits. Additional forms may be obtained form either the Special Events Coordinator
or UAS Supervisor.
Number of Copies and Distribution:
2 copies (original and 1 photocopy)
Original - EMS Supervisor
Photocopy - EMS Supervisor
Instructions:
Event/Location: Document the special event and the location where the incident
occurred. (i.e. "Arts Fest First Aid Trailer.")
Last Name, First: In the space provided, write the last name, then the first name of
the patient.
Street Address: Document the street address of the patient - may be local or
permanent address.
City, State, Zip: Write in the patient's city and state of residence; also include
current zip code.
SS#: Document the patient's social security number.
Student: Yes No: Indicate whether or not the patient is a PSU student. Circle the
appropriate response.
Incident #: Incident numbers are sometimes used for larger events such as Dance
Marathon and Special Olympics. The operating Special Event Coordinator will
inform crew on whether to leave this section blank, or number it, or it may be
prenumbered.
Date: Document the date of which the incident occurred. Time In: Document the
time in military format that the patient came in contact with UAS crew.
Time Out: Document the time (military form) in which the patient was released to
coaches, parent's, transporting ambulance crew, etc.
Age: Write in the age of the patient.
Sex: Write in the gender of the patient.
Nature and Location of Injury/Illness: Indicate the patient's "chief complaint"
about their medical condition, be it illness or traumatic injury.
A/R: Yes No: Indicate, if known, whether or not the incident was "alcohol
related". If unknown, leave blank.
History of Present Illness: Document the events leading up to and/or causing the
incident. This section is subjective to what the patient, bystanders, etc. tell the
attending EMT.
Past Medical History: Document any past medical problems that the patient has had.
Allergies: Indicate any known drug allergies the patient has.
Current Medications: Indicate any medications the patient is currently taking.
Time: Document times (military style) of all patient treatments/interventions.
Intervention (Treatment/Vitals): Document all treatments performed and all vital
signs obtained.
Results of Intervention: Indicate the patient response to any treatments
administered.
Final Patient Disposition: Document the final outcome of the patient. This means
what the patient condition was at the time of patient care transfer and also the
facility, personnel, etc. to which the patient was released to. (i.e. "Patient released
to UAS ambulance crew for transport to Centre Community Hospital.)
Refusal (over): Place a check mark in the box provided if the patient signed for
a refusal of treatment/transport.
Attendants: Name: EMT#
Document the names and certification (EMT) numbers of all attending UAS crew
for this particular incident.
Reverse Side:
This is to certify that I, _______________: Print the patient's full name on the
line provided.
Date: Document the date of which the incident occurred and hence the date of
patient refusal.
Patient's Signature: Have the patient sign full name on the line provided.
Witness: Obtain witness signatures (there are two such spaces on the form) from
bystanders, parents, other UAS crew members, etc.
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SPECIAL EVENTS LOG
Purpose:
This form is used to log all incidents which occur at special events by UAS crew
members working the events.
Where to Obtain Form:
Forms are kept in the special events log book located in the duty room. Additional
copies may be obtained from the Special Events Coordinator.
Number of Copies and Distribution:
1 copy (original)
Original - Special Events Log Book
Instructions:
Date: Document the date of the incident and special event.
Time: In military format, document the time in which the incident occurred at the
special event.
Patient Name: Write the patient's full name in the space provided.
Location: In the corresponding column, write in the location of the incident (i.e.
Dance Marathon - White Building Gymnasium).
Inc. Type: Indicate the type of incident involved. Such incidents include fall victim,
allergic reaction, altered level of consciousness, etc.
Transport Y/N: Indicate whether or not the patient was transported from the event
to an appropriate facility. Indicate so by writing a "Y" in the blank if the patient was
transported, or a "N" in the blank if the patient was not transported.
Refusal Signature: If indicated, state whether or not a refusal signature was obtained.
If the incident did not warrant a refusal signature, write "N/A" in the blank.
Event: Document the specific special event in which the incident occurred.
EMT: Document the last name and UAS 20-# of the attending EMT of the
incident.
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SPECIAL EVENTS REQUEST FORM
Purpose:
This form is to be completed by the EMS Supervisor upon notification of
upcoming special events.
Where to Obtain Form:
Forms are stored in the UAS EMS Supervisor's office in the filing cabinet labeled
"Special Events."
Number of Copies and Distribution:
1 copy (original)
original (EMS Supervisor)
Instructions:
Date Contacted: Indicate the date of which UAS first received notification of the
special event.
Special Event: Indicate the name of the special event in consideration.
Contact Person: Write in the full name of the contact person in charge of
administration of the special event. Address/Phone #: Document the address and
phone number of the contact person named above.
Date(s): Document the specific dates of the special event to be staffed by UAS EMTs.
Time(s): Indicate the time(s) in which the event must be staffed by UAS EMTs.
Location: Write in the scheduled location and possible rain locations for the special
event.
Description of Events: Indicate in as much detail as possible the type of event(s) to
be held.
Number of Participants: In as close an estimate as possible, indicate the expected
number of people participating in the event.
Number of Attendees: Estimate as closely as possible the number of spectators, etc.
expected to attend the event. Other Pertinent Information: Document any other
information that may be pertinent for the attending EMTs. Number of EMTs
Assigned: Write in the number of EMTs scheduled to work the event.
Ambulance: Check the appropriate response whether or not an ambulance is
scheduled to stand-by at the event. Check "yes" if an ambulance is to be on stand-by,
or "no" if an ambulance is not needed.
Payment: Indicate the mode in which payment for UAS services is to be made.
Mark either "IDT" or "Check".
Date Billed: Document the date in which the bill was sent to the administration of
the special event.
Date Payment Received: Document the date in which the payment for UAS EMS
was received.
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THIRD PERSON EVALUATION FORM
Purpose:
This form is completed by UAS crew members for the evaluation of a trainee at the
completion of the shift.
Where to Obtain Form:
Forms are located in the trainee filing cabinet in the UAS duty room, room 21
Ritenour.
Number of Copies and Distribution:
1 copy (original)
original - Third Coordinator
Instructions:
Name: Write in the full name of the trainee.
Certification Number: Write in the PA state certification number if applicable.
Date: Document the date of the call of which the trainee is being evaluated.
Appearance: On a scale from 0 through 5, with 0 = did not perform skill, 1 = poor, 5
= excellent, rate the trainee in terms of general appearance for uniform and general
appearance.
Professionalism: Using the rating scale from above, rate the trainee's
professionalism regarding how well the trainee interacted with patient(s), crew,
hospital staff, and Medic 24.
Performance: Rate the trainee's aptitude demonstrated during the following:
patient assessment, patient care, patient care equipment, trip sheet, driving, radio
skills, clean up, and rig check.
Attitude: Rate the trainee's attitude concerning eagerness to learn and interaction
with crew daily duties.
Comments: Document any comments, positive or negative, concerning any aspect
of the trainee's performance during the shift and any calls taken.
Reverse Side:
This section to be completed by the third person.
Did the crew answer any questions you may have had?: Indicate whether the duty
crew was helpful in answering any questions you may have asked during the shift
or any calls. -
Did the crew offer to teach you any new, or improve any of your skills? Write down
comments regarding the crew's willingness to work with you on training for new
skills or improving on current skills. Document any training, such as driver
training, traction splinting, etc that was done during the shift.
Do you feel that the crew attempted to make you a necessary and functional unit of
the "team" before, during, and after any incidents or events?: Indicate whether the
crew made an attempt to include you, as a trainee in the daily routine duties as well
as assisting with any calls.
Do you feel sufficient opportunity was given to review the good and bad points of
the crew's performance on any calls or events?: Briefly explain if you were satisfied
with the evaluation and discussion about the entire crew's performance after any
calls taken during the shift.
Do you feel this evaluation was completed in a fair and accurate manner consistent
with your performance? If not, why?: In your opinion, as a UAS trainee, describe
whether or not you think that the crew was fair in their evaluation of your
performance. If you feel their evaluation was unfair, describe why you think so.
Comments: Document any comments you have regarding the shift, crew, etc.
Signature Third Person: The Trainee must sign his full name on the line provided.
Date: Document the date in which this section of the evaluation form was
completed.
This section to be completed by crew members:
Do you feel the above questions were answered in a fair and accurate manner? If
not, why?: The crew member(s) should indicate if they think that the trainee's
comments from the preceding section are valid. If the crew disagrees with any of
the trainees comments, they should describe why.
Signature Crew Member: Both crew members should sign their full names on the
two lines provided.
Co. 20 Number: Document the current Company 20 number(s) for the duty crew.
Date: Document the date of which the crew members signed the evaluation form.
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TRAINEE CALL EVALUATION FORM
Purpose:
This form is to be completed by UAS crew members and trainees after an ambulance
call. The form is intended to review the performance of the trainee.
Where to Obtain Form:
Forms are located in the "Trainee" filing cabinet located in the UAS duty room,
room 21 Ritenour Building.
Number of Copies and Distribution:
1 copy (original)
original - UAS Third Coordinator
Instructions:
Trainee Name: Write in the full name of the trainee.
Certification Number: Write in the PA state certification number if applicable.
Date: Document the date of the call of which the trainee is being evaluated.
Type of Call: Describe the type of ambulance call the trainee was attending.
Was the Trainee in Charge of Patient Care? Yes/No: Circle the correct response if
the trainee took patient care on the ambulance call.
If Yes: Rate the Trainees Performance With: Indicate the appropriate response for
the trainees evaluation of Patient Interaction, Physical Exam, Treatment Skills,
Med Patch, Interactions with Hospital, Medics, etc. The rating scale is a scale based
on 1 - 5, with 1 being "poor" and 5 being a rating of "flawless". If the skill was not
performed by the trainee, mark "N/A".
Comments: Describe the reasons why you rated the trainee as you did in the
preceding section.
If No, Why: If the trainee was not in charge of patient care, indicate why they were
not.
What Skills Were Performed: Outline what skills the trainee performed on the
call, even though he may not have had full patient care, (i.e. vitals, 02 therapy)
Were all aspects of this evaluation discussed with the trainee? Yes/No: Indicate
whether or not the evaluation was discussed with the trainee being rated. Circle the
correct response.
Additional Comments: Document any problems, incidents, or other comments
concerning the trainees performance on the ambulance call.
Reverse Side:
To be completed by Trainee:
Do you feel you have been evaluated fairly Yes/No? The trainee should indicated
whether or not he feels that the duty crew evaluated him fairly.
If NO, Why? Explain why you feel that you were not evaluated fairly.
Has the Crew gone over this eval with you? Yes/No? Circle "yes" if the duty crew
explained the evaluation form with you, and "no" if the crew did not.
Are there any comments you wish to leave for the Trainee or Training Officers
about this eval or the call that it was filled out for? Yes/No: Indicate and comment
if necessary any pertinent comments/suggestions for the officers overseeing
trainees.
To Be Completed by Crew:
Do you agree with the trainee's responses above? Yes/No: Circle the response you
feel best fits your opinion of the trainees comments regarding the crew and the
evaluation form.
Comments: Describe any further comment you may have regarding the trainees
performance on the call.
Crew Signature: These two sections must be signed by both crew members.
20-Number: Document the duty crew UAS CO. 20 numbers.
Date: Document the date this form was reviewed and completed.
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VEHICLE ACCIDENT REPORT
Purpose:
This form (G1.44) is used to report the essential facts of a motor vehicle accident
whenever a University-owned vehicle (or privately-owned vehicle being used on
University business) is involved.
Where to Obtain Forms:
Furnished by Risk Management Office, 865-6307. Forms are provided in the glove
compartments of all University-owned vehicles.
Number of Copies and Ultimate Distribution:
Original - Blue - Risk Management Office
Retention Period (See Appendix 21):
Current fiscal year plus 2 years
Where to Send Completed Forms:
At University Park locations, the driver concerned will bring or send the form to the
Risk Management Office at once.
At non-University Park locations, the form must be reviewed by the local Director
of Business Services for Commonwealth Campuses, Director of Operations at Penn
State Erie - The Behrend College, and the Manager of Human Resources and
Business Services at Penn State Harrisburg, before being forwarded to Risk
Management.
Instructions:
Complete both sides of the form, answering all applicable questions, and sign the
form in the designated space.
Have your supervisor or department head sign the form, verifying that the accident
was properly reported and the vehicle was authorized for a permissible use.
General Information:
All information called for on this form is important and, generally, can best be
obtained at the time of the accident. If for some reason (such as injuries) all the facts
cannot be secured immediately, the form should be submitted anyway, followed as
soon as possible by an amplifying report. On the basis of the completed form
submitted, the Risk Management Office can then, in turn, file the required accident
report with the insurance company.
If you are involved in an accident in which someone is injured or killed, or if any
vehicle is damaged to the extent that it cannot be driven, you must immediately
notify the local or state police. YOU NO LONGER HAVE TO SUBMIT AN
ACCIDENT REPORT TO THE DEPARTMENT OF TRANSPORTATION UNLESS
FOR SOME REASON THE POLICE ARE UNABLE TO INVESTIGATE THE
ACCIDENT.
REPORT OF INJURIES BY DEADLY WEAPON OR CRIMINAL ACT
Completion of this form in duplicate is required under Section 5106 Pennsylvania
Code. Complete in all cases embraced under the Act, as posted as GUIDE FOR
REPORT OF INJURIES BY DEADLY WEAPON OR CRIMINAL ACT and in
accordance with instructions below.
TO OFFICER IN CHARGE OF POLICE FORCE HAVING JURISDICTION WHERE
THE INCIDENT OCCURRED. Give name of Township, Borough, City, and County,
and name of officer to whom reported.
On the of , 19 , at o'clock A.M., P.M.
Name Age
Address Phone No. was brought to the Pennsylvania
State University Health Services suffering from the following injuries:
Give a brief description of how the incident occurred, and name(s) of persons
involved other than the patient:
Geographic location where incident occurred -- also names of places if available:
Information was given by
Living at Phone No.
This confirms telephone report made to your office on
at o' clock AM/PM by of the Pennsylvania State University Health Services.
Disposition: Admitted Discharged Transferred to C.C.H.
FOR ADMINISTRATOR'S USE ONLY.
Mailed to:
Reporting Individual's Signature
Date and Time mailed:
Two copies of this report are to be sent to the Medical Director's Office within 24
hours arrival of victim at the UHS -- one for mailing, one for filing.
If the report is filed during the time EDST is in effect, the time recorded will be
understood to be EDST; otherwise, the time stated is to be understood to be EST.
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OXYGEN SURVEY REPORT
DATE TRIP NUMBER
Call Type
Was oxygen used: YES NO
If yes, check which protocol was followed:
-Pulse less than 40 or greater than 110
-Respiratory rate less than 12 or greater than 24
-Cyanosis
-Suspected cardiac or cerebral ischemia, or significant blood loss
-Significant chest, abdomen, head, or pelvic injury
-Recent or current seizure activity
If oxygen was or was not used according to protocols, give reason below
To be filled out on every call and attached to trip sheet.
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02.22.02