DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 7300 (Rev. 01/01)
Date Incident Reported
AMBULANCE RUN REPORT (Page 3) Skills / Extended Comments
Completion of this form meets the requirements of administrative rule HFS 110.04(3)(b). Client information in this document is confidential under Wis. Stat. 146.82(1).
STATE OF WISCONSIN Adm. Code HFS 110.04(3)(b)
Patient Care Record / Alarm No.
Patient Last Name / First / MI
Service Name and ID No. Cardiac Rhythm Interpretation Blocks
Responding Unit
Time
EMT
Blood Pressure
Rate
Pulse Quality
Rate
Resp Quality
SPO2
Procedure
No. of Attempts (Joules for Defib) Success
Medications
Dose
Route
A D V A N C E D S K I L L S
Airway complications o Nasal o None o Dental o Pharyngeal o Other _________ o N/A o Esophagus o Trachea Equipment Failure Differential Diagnosis Additional Comments
Airway Placement verified by EMT o Auscultation o Tube Check o Visualization o End Tidal CO2 o N/A
Airway Placement Prehospital Outcome ER Outcome o Admitted to Hospital Hospital Outcome verified by MD o Transferred o Transferred o Discharged Arrived at Hospital w/ Pulse o Discharged o Discharged AMA o Died o Unknown o Died oYes o No oN/A o Yes o No o Unknown o N/A
o Yes o No
Explain:
oN/A
ALS Provider Arrival:
o N/A
SIGNATURE -- Medical Control Physician SIGNATURE AND NUMBER -- EMT SIGNATURE AND NUMBER -- EMT