Patient Treatment Form

⬇ Download Patient Treatment Form

General information

• Date
• Time
• Team
• Sector
• GPS location

Contact details

• Treated by
• Qualification
• Telephone number
• Email

Patient details

• Name
• Age
• Nationality
• Gender

Handover to

• Locals/family
• Ambulance
• Hospital
• Mortuary
• Medical team
• Helicopter
• Field hospital
• Other

Type of Entrapment/Incident

Victim contact

• First detection
  • Date and time
• First USAR contact
  • Date and time
• First physical contact
  • Date and time
• Extrication
  • Date and time

Injuries identified and add details

• Penetrating Trauma
• Amputation
• Burns
• Crush
• Head Injury
• Blunt Trauma
• Dehydration
• Fractures
• Blast
• Other

Vital signs (where applicable)

• Respiratory rate
  • Time/Date
• Pulse
  • Time/Date
• Blood pressure
  • Time/Date
• AVPU/GCS
  • Time/Date
• Blood glucose
  • Time/Date
• SPO2
  • Time/Date
• ETCO2
  • Time/Date
• Temperature
  • Time/Date
• Urine output
  • Time/Date
• Other
  • Time/Date

Treatment given

• Interventions
  • Time/Date
  • Total
• Fluids
  • Time/Date
  • Total
• Drugs
  • Time/Date
  • Total

Additional information

Form filled in by

• Name
• Title
• Signature