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					                         Contra Costa County EMS Patient Reporting (Handoff) Guidelines
              Objective: To improve patient safety & team interaction by providing concise, complete and clear communication

                       Field to Field Handoff           Receiving ED Handoff            Trauma Handoff: MIVT Patient                STEMI Center Patient
                                                                                                  Report                                 Handoff
Situation            Patient identification, age,
                     gender & MR # (if known).
                                                      Patient identification, age,
                                                      gender & MR # (if known).
                                                                                       Patient identification, age, gender &
                                                                                       MR # (if known)
                                                                                                                                Patient identification, age, gender
                                                                                                                                & MR # (if known)
What is the                                                                            Mechanism of Injury: ie: MVA,            STEMI Alert confirmed by
situation?           Chief complaint/Mechanism of     Chief complaint/Mechanism of     rollover, ejection, GSW, blunt trauma    ***ACUTE MI*** (Zoll)
Urgent issues?       Injury                           Injury                           Urgent concerns up-front                 ***Acute MI Suspected*** (LP-12)
                     Identify immediate needs         Identify immediate needs                                                  Urgent concerns up-front
                     Urgent concerns up-front         Urgent concerns up-front
Background           Presenting complaints and
                     symptoms
                                                      Presenting complaints and
                                                      symptoms
                                                                                       Injuries Sustained/LOC:
                                                                                       What are the patient’s major injuries.
                                                                                                                                Presenting complaint
                                                                                                                                Pertinent past cardiac Hx including
                     Pertinent past medical history   Pertinent past medical history   Does not need to be all-inclusive        past cardiac surgeries.
What happened        including:                       including:                       Level of consciousness: AVPU             Pacemaker placement
up to this point?    High Risk Medications:           High Risk Medications:           format. Include changes en route or      Pertinent past medical Hx
                     Anticoagulants, Insulin,         Anticoagulants, Insulin,         on scene                                 including:
What past hx         Digoxin, ERD’s, etc.             Digoxin, ERD’s, etc.                                                      High Risk Medications:
would be             Advanced directives if known     Advanced directives if known                                              Anticoagulants, Insulin,
                     Allergy and Medication Hx        Allergy and Medication Hx                                                 Digoxin, ERD’s, etc.
important to treat   Patients with SOB                Patients with SOB                                                         Advanced directives if known
the patient                    Use PASTE                        Use PASTE                                                       Allergy and Medication Hx
further?             Presence or absence of drugs     Presence or absence of drugs                                              Cardiologist if known
                     or alcohol.                      or alcohol.

Assessment           General Impression
                     State pertinent findings ie:
                                                      General Impression
                                                      State pertinent findings ie:
                                                                                       Vital Signs
                                                                                       Blood pressure: If known, otherwise
                                                                                                                                General Impression
                                                                                                                                State pertinent findings ie:
How is the           physical findings, VS, ALOC,     physical findings, VS, ALOC,     quality/location of pulse Pulse: Rate    physical findings, VS, ALOC, etc
patient now?         etc                              etc                              and quality                              Pain Level
Improved or                                                                            Respiratory rate: Add abnormal lung
worse since on                                                                         sounds if noted
scene?                                                                                 ECG rhythm: If anything other than
Patient stable or                                                                      NSR or sinus tachycardia
unstable?                                                                              Pulse oximetry: If known

RX Recap             Treatments given & patient
                     response.
                                                      Treatments given & patient
                                                      response.
                                                                                       Treatment(s)
                                                                                       Field care review and patient
                                                                                                                                Prehospital treatments given &
                                                                                                                                patient response.
What field care      Restate concerns as needed       Restate concerns as needed       response                                 12 lead hardcopy to RN.
given?               Respond to questions.            Respond to questions.            Verify that all information has been     Restate concerns as needed.
Was it effective?                                                                      received.                                Respond to questions.
Concerns?                                                                              Restate concerns as needed.
                                                                                       Respond to questions.
                        Contra Costa County EMS Patient Reporting (Handoff) Guidelines
              Objective: To improve patient safety & team interaction by providing concise, complete and clear communication

                        Receiving Facility               Trauma Center Radio Contact                          STEMI Alert Radio                   Base Radio Contact
                         Radio Contact                                                                            Contact
Situation               Agency name & unit #        Agency name and unit #                              Agency name and unit #                   Agency name and unit #
                        ETA & response code         State “Trauma Destination Decision” or              Identify call as STEMI Alert             State why calling:
                        Pt age and gender           patient meeting “High-Risk” criteria.               ***ACUTE MI*** (Zoll)                         AMA
What is the             Chief complaint             ETA to trauma center.                               ***Acute MI Suspected*** (LP-12)              Field guideline
situation?              Urgent concerns             Pt age and gender                                   ETA to STEMI Center                           variation
                        up-front                                                                        Patient age & gender                          Destination
Urgent issues?                                      Urgent concerns up-front.                           Urgent concerns up-front                      MD on scene
                                                    If Trauma destination request- state                                                              Additional orders
                                                    destination you believe needed.                     If pt elects to go to facility that is   Pt age, gender, chief
                                                                                                        not STEMI designated inform              complaint
                                                                                                        receiving hospital.                      Urgent concerns up-front
Background              Presenting complaint        Mechanism of Injury/ Injuries Sustained             Presenting complaint and                 Presenting complaint and
                        and symptoms.               Chief Complaint. State patient’s major injuries     symptoms                                 symptoms.
                        Pertinent past medical      and LOC.                                            Pertinent past cardiac history           Pertinent past medical
What happened           history.                    Basic scene information:                            Pacemaker placement                      history.
up to this point?                                              Seatbelt or helmet use
What past hx would                                             Airbag deployment
be important to treat                                          Prolonged extrication
the pt further?                                                Estimated MPH if known
Assessment              General Impression          Primary Survey and pertinent positives              General impression                       General Impression
                        State pertinent findings    ABCD (can report as ABCD normal except…..)                                                   State pertinent findings ie:
How is the              ie: physical findings,VS,   Report if abnormal:                                 Pertinent vital signs and physical       physical findings,VS, ALOC,
patient now?            ALOC, etc                              Airway (if not patent)                   exam ie: physical findings,VS,           etc supporting request.
Improved or worse                                              Breathing (labored, shallow, or rapid)   ALOC.
since on scene?                                                Circulation (altered perfusion, shock)
Patient stable or                                              Estimated blood loss                     Pain level
unstable?                                                      Disability : AVPU include any changes
                                                    If pertinent Vital Signs , ALOC
RX Recap                Prehospital treatments      Treatment(s)                                        Prehospital treatments given &           Prehospital treatments given
                        given & patient             Prehospital treatments & patient response           patient response                         & patient response
What field care         response                    Restate concerns.                                                                            Restate concerns.
given?                  Restate concerns.           Respond to questions.                                                                        Respond to questions.
Was it effective?       Respond to                  Request direct online MD consultation as                                                     Request direct online MD
Concerns?               questions.                  needed.                                                                                      consultation as needed

				
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posted:7/30/2011
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