Complete this form for: • EMS dispatched for presumed OOH-CA • PAD volunteer system activation for Presumed cardiac arrest: - any CPR was attempted (includes moving patient) - the AED was turned on or pads applied • Any shock delivered • Patient found dead, but EMS not notified Data Resources: Dispatch Center, Volunteer, EMS
Episode Log
patid31 Patient ID:
page 1 of 1
44352
(Site)
(Patient)
(Chk)
Entity Name:
patsit31
patnum31
patchk31
Time dispatch call received (estimate if EMS not called)
1.
Date of Episode:
Time of Episode
Entity ID:
entid31
/
(month) (day)
/2 0
(year) date31
:
(24 hour clock) (Site) (Unit) (Entity) (Chk)
advsit31 2.
3.
tmepsd31 Yes Did this episode involve an Adverse Situation?
1 0
entsit31 entunt31 entnum31 entchk31 Don't know yet
Was a PAD or non-EMS AED applied?
1
Yes, PAD AED No Yes, Other AED
padaed31
0 2
AED ID: aedid31 (Site) (AED) aedsit31 aednum31
(Chk)
aedchk31
4.
Nature of Call: How was the call reported to the dispatcher? (check one only)
1
Found down (sudden collapse, presumed CA, Seizure SOB/CP
unconscious)
4 5 6
Sick/weak "Help" - NOS Other
nature31
2 3
5.
disp31
Disposition: (check one only)
1 2 3
Patient alive, not transported to ED/hospital DOA, No resuscitation attempted Died in field, DNAR
4 5 6
Died in field, resuscitation attempted Died in ED Alive, Transported to ED/hospital
carout3 6. 1 heim31
1
a) Was cardiac arrest ruled out by EMS at the scene? b) Was the Heimlich performed by a PAD volunteer? c) Were ventilations performed (by anyone)? d) Were compressions performed (by anyone)?
Yes Yes Yes Yes
0
No No No No
vent31
Note: CPRPRF31 is obsolete in this version.
comp31
7.
Information obtained from: (check all that apply) volidi31 (Volunteer) disctr31 (Site) (Unit) Dispatch Center
(Chk)
(Acrostic)
volntr31
emsinf31
Volunteer EMS Other:
ID:
vlsiti31
(40)
vlunti31
vlnumi31
vlchki31
volaci31
othinf31
spinfo31
8.
volidp31 vlsitp31 Volunteer(s) Involved: (primary)
(Site)
(Unit)
(Volunteer)
(Chk)
(Acrostic)
vluntp31
vlnump31 vlchkp31
volacp31
volido31 (other)
vlsito31
code31
Signature of person filling out this form
vlunto31
vlnumo31 vlchko31
For CTC Use Only
volaco31
Yes No
Code Number
1 3 1 0 4 0 0
version 04.00 06/12/03
EPILOG
WEB / FAX (1-888-437-4767)