how to fill out your ice (in case of emergency) form: who...

I.C.E. Forms a product of Patient Pathways, Vancouver BC | [email protected] | 604-440-6795

How to fill out your ICE (In Case of Emergency) form:

Who should fill out this ICE form?

Anyone and everyone of all ages! In your household, whoever lives there, should have one of these

meticulously filled out.

Why should we fill out this ICE form? In a time of crisis, we always forget something important about ourselves or our loved ones. This can literally mean the difference between life and death.

First responders and paramedics often spend a great deal of their time searching people’s homes to find their medications, and any other pertinent information that may help them when you have dialled 911< especially when you can’t speak for yourself; It’s just as important to have this type of information compiled for the person you are caregiving for. When a crisis arises, we often forget many important items that need to be immediately available for the best care for ourselves and our loved ones.

You are making an important step by filling it out so you can help yourself get the best possible medical care in a medical crisis. This form, when completely appropriately, will give first responders, paramedics and hospital emergency staff critical information that they need to help you effectively and efficiently when you are not readily able to speak for yourself. First-line medical emergency people do not have immediate access to your medical records, but need this information quickly and comprehensively.

Take the time to go through all your pertinent medical history, medications and other issues. Hopefully you will never need to access this. But, if you do, you have just maximized your opportunity for the best care possible, at all levels< pre-hospital, in the emergency room and in the hospital.

People often say they have a great sense of relief and piece of mind when this is done and kept up to

date.

When to fill this form out? Now! Date the form when you fill it out. Then, every time there is a change to your health, your medication or situation you should update the form and date it again. You will see where to do this as we go along.

We have laid out step by step instructions below on how to fill in each section appropriately.

When you have finished, we strongly suggest that this be posted on your fridge, in a clear plastic folder. This is where all emergency personnel look for important medical information for people. And,

you can put a card in your wallet stating that this information is at home on the fridge, so your designated person can get it in a timely manner. We suggest you also take a picture of the completed form on your phone so that you have this information with you always.


This clear plastic folder can also hold your representation agreement and your advanced directives, along with other critical documents (a list is on page one). These need to be easily and quickly accessible so that your wishes can be followed as you have laid them out. You have been in charge of your life, your whole life, and you have now taken the time to document how you would like to live if a medical emergency arises. All of these documents tell those treating you KNOW exactly what you want so they can honour your directives.

So let’s get started!

How do I fill out this ICE document?

Gather ALL your medications, supplements, your medical card and medical documents so that you

can refer to them as we go through each section.

Cover page:

We understand that people would like a little privacy with this information when they post it on the

front of their fridges. Fill this cover page out and put it on the very front of your package. While your

privacy is important, it is more important to have this information readily available for the first

responders and paramedics.

We have added reminders of when to review and update your ICE information.

Page 1: This is your basic information. Provide ALL requested information. Your primary language is important because, sometimes, when you have something go wrong or you are stressed, you might revert to your “mother tongue”; Medical staff can make every effort to seek out someone to help translate if needed. Note here if you also speak English.

FORMS INCLUDED IN THIS PACKET:

Only check boxes when you have put these specified documents into this clear plastic folder. Be sure

that all of the included documents are filled out completely. And always make sure you have copies of

these papers securely filed somewhere else in your home. Originals required to be here include: No

CPR, or MOST, and/or Expected Death in the Home. The rest can be copies.

IMPORTANT CIRCUMSTANCES:

This is for very specific issues that apply to you that need to be brought up immediately for

pre-hospital or emergency staff. For example: you are deaf without your hearing-aides; you live with

your mentally challenged child and he does not react well to strangers; or, you care for someone with

dementia that will need attention. If you collapse, the first responders need to have this information

so they can look for instructions on how to deal with this or who to phone in an emergency (listed

later in this form).


MEDICAL CONDITIONS AND RECENT SURGERIES: These are your diagnoses that you are dealing with right now. For example; congestive heart failure, diabetes, high blood pressure, cancer (what type and where), etc.

For recent surgeries, list from most recent. For example; you may have had your tonsils out when you were 5 years old, but that bowel resection last year needs to go first.

This is also where you would record about your pacemaker, or automatic defibrillator.

Page 2:

Your name & PHN (personal health number) go at the top of each page, in case the pages get separated!

ALLERGIES:

Allergy is defined as: a condition of being made ill by a particular drug, food, or chemical.

Some of these “conditions” are life threatening and some are just annoying; Put ONLY

life-threatening allergies or those that make you very ill.

For example: bee stings – some people have a little itching and small amount of swelling after a

bite=annoying. Other people can have a system wide reaction which can very well kill them. Both are

defined as allergies. Start with the most severe reactions first, and what the reaction is.

MEDICATION RECORD: Follow the columns and fill it all out. ALL medications are important, so list them all: prescription AND over-the-counter, (such as aspirin or Tylenol). Note: if you discontinue a medication, just put a single line through it with a date beside it.

Drug = name of on prescription Form = pill, liquid, injection, topical, etc Dosage = how many milligrams/micrograms is the dose When taken = what time of the day Taken for = your “water pill” is for your high blood pressure, etc. Prescribed by = which doctor prescribed this for you and their full name

At the very bottom of this section, note where you keep these pill bottles in your home: kitchen, bathroom, bedroom, refrigerator. If you can, direct the first responders find the pill bottles if they need to clarify something and/or take them with you to the hospital.

SUPPLEMENTS, OINTMENTS AND ANY OTHER NON-PRESCRIPTION:

Same as medication record, list it all, dosages and when and why you take it. And where to find all of

the bottles, tubes, ointments, etc.


MOBILITY AND SENSORY ISSUES: Please tick the appropriate boxes and leave notes that might be helpful here. For example: you might be

legally blind but still wear glasses. It’s important to have your glasses, hearing aides, and dentures with

you when transferred to hospital.

EMERGENCY CONTACTS: These are the people you want to speak for you when you cannot in a medical emergency. This would be

your medical representative and others you have had conversations with and knows what you would like

to happen with your life should some catastrophe happen.

These are not the person who will water your plants or feed your cat<<that will be a little further in this document. We have not forgotten the cat (or dog or other pet or plants, etc.) but your health first, so hopefully you can get back to feeding the cat, or plant.

CURRENT PHYSICIANS: List only your current or most recent specialists.

PERSONAL AND HOUSEHOLD CONTACTS:

And here is where we get to feeding the animals, watering plants and bringing in the mail people. This

team that you have, that will be there that if you suddenly end up in hospital for a week, or a month,

will be able to keep your home safe while you are away. This peace of mind for this cannot be

understated.

Updating this information:

Review your documents once per year OR when any of the following occur:

Any medication changes

A change in diagnosis or health status

A hospitalization

A change in Representative or Substitute Decision Makers

Review this information once a year (with all of your Advance Care Planning

documents); Pick a date: birthday, anniversary, change to Daylight Savings time< Mark it on your calendar and keep it at the top of your to-do list. Your life may depend on it. Thank you for taking the time to fill out this document. It literally might mean the difference between your life and death. But it will certainly mean that you will get all the important and pertinent information to the right medical personnel, pre-hospital and in the emergency ward when you need it the most.

If you would like assistance filling this form out, please contact Patient Pathways at www.patientpathways.ca or 1-604-440-6795 and we would be happy to have someone help you through this process appropriately.

http://www.patientpathways.ca/


In Case of Medical Emergency

Forms for:

Name: _______________ Completed: ____________

Reviewed: ______________ Reviewed:_______________

Name: _______________ Completed: ____________


Name: _______________ Completed: ____________


Paramedics & First Responders

please read & take to hospital

Review your documents annually OR when any of the following occur:

Any medication changes

A change in diagnosis or health status

A hospitalization

A change in Representative or Substitute Decision Makers

Name: PHN:

[email protected]

https://patientpathways.ca (604) 440-6795

© Patient Pathways 2018

Medical Information IN CASE OF EMERGENCY CALL 911

Full name [Last name, Given names] Address Main phone

Alternate phone

Personal Health Number

Birth date [yyyy-mm-dd]

Date completed [yyyy-mm-dd]

Primary language

FORMS INCLUDED IN THIS PACKET No CPR OR Medical Orders for Scope of Treatment [MOST] stating no CPR AND level of intervention Representation Agreement

Advance Directive

Expected Death in the Home [EDitH] [For those nearing end of life] Enduring Power of Attorney OR Power of Attorney

Organ donor status

Funeral arrangements and after-death care of body instructions Other important details can be found:

IMPORTANT PRIORITIES MEDICAL CONDITIONS & RECENT SURGERIES Condition

Date diagnosed or treated [yyyy-mm-dd]

Notes

Condition


Notes

Condition


Notes

Condition


Notes

Condition


Notes

Condition


Notes

Condition


Notes

Condition


Notes

https://patientpathways.ca/

Name: PHN:

[email protected]



LIFE THREATENING ALLERGIES Allergen

Reaction

What to do

Allergen

Reaction What to do Allergen

Reaction What to do

MEDICATION RECORD Drug

Form

Dosage

When taken

Taken for

Prescribed by

Drug

Form

Dosage

When taken

Taken for

Prescribed by

Drug

Form

Dosage

When taken

Taken for

Prescribed by

Drug

Form

Dosage

When taken

Taken for

Prescribed by

Drug

Form

Dosage

When taken

Taken for

Prescribed by

Drug

Form

Dosage

When taken

Taken for

Prescribed by

Drug

Form

Dosage

When taken

Taken for

Prescribed by

Drug

Form

Dosage

When taken

Taken for

Prescribed by

Drug

Form

Dosage

When taken

Taken for

Prescribed by

Where these medications are kept: NON-PRESCRIPTION MEDICATIONS, OINTMENTS & SUPPLEMENTS Drug

Form

Dosage

When taken

Taken for

Recommended by

Drug

Form

Dosage

When taken

Taken for

Recommended by

Drug

Form

Dosage

When taken

Taken for

Recommended by

Drug

Form

Dosage

When taken

Taken for

Recommended by

Drug

Form

Dosage

When taken

Taken for

Recommended by

Drug

Form

Dosage

When taken

Taken for

Recommended by


Name: PHN:

[email protected]



MOBILITY AND SENSORY ISSUES Paralysis Wheelchair Walker Cane Scooter Prosthetic limb Dentures Swallowing

Autism spectrum Nonverbal Low/No hearing Hearing aid Low/No vision Eyeglasses Contact lenses Other:

MEDICAL EMERGENCY CONTACTS Name

Relationship

Primary phone

Secondary phone

Name

Relationship

Primary phone

Secondary phone

CURRENT PHYSICIANS Family physician

Telephone

Notes Specialist physician

Telephone


Telephone


Telephone


Telephone

Notes


Name: PHN:

[email protected]



PERSONAL AND HOUSEHOLD CONTACTS Name

Telephone

Role Notes Name

Telephone

Role Notes Name

Telephone

Role Name

Telephone

Role Notes NOTES


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