operations manual stratford emergency...
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OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SECTION: 4-1: DAILY INCIDENT LOG AND MANUAL
HOURS REPORT
DATE ISSUED
OR REVISED:
01-NOV-2004
PURPOSE: To establish a procedure to maintain a log of all Department responses
4-1.0 DAILY INCIDENT LOG AND MANUAL HOURS REPORT
4-1.1 All Department responses shall be logged on the Daily Incident Log
4-1.1.1 The log is maintained at Department headquarters.
4-1.1.2 The Crew Chief is responsible for ensuring that each response is
logged.
1 All responses, including those canceled en route, shall be
included.
4-1.2 All personnel who did not sign in using the electronic system should enter their
hours on the Manual Hours Report
4-1.2.1 The hours will be manually entered into the system by the
Administration.
4-1.3 Sample Form
4-1.3.1 A Sample of this form is attached on the following pages
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OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
STRATFORD EMERGENCY MEDICAL SERVICE 900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.stratfordems.com
DAILY
INCIDENT
LOG
INSTRUCTIONS:
This form shall be completed for EVERY response, including �canceled en route�
assignments. For incidents with no patients, remember that a Standard Patient
Runform must still be completed indicating the nature and disposition of the response.
TODAY�S DATE: _______ / _______ / _______
NUMBER OF
CASE NUMBER TIME INCIDENT LOCATION RUNFORMS
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
STRATFORD EMERGENCY MEDICAL SERVICE 900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.stratfordems.com
MANUAL
HOURS
REPORT
INSTRUCTIONS:
All personnel who did not sign in using the electronic system should enter their hours
on this form. Hours will be manually entered into the system by the Administration.
UNIT AND COMMENT
YOUR ID # TIME IN TIME OUT JOB DESCRIPTION (page crew, system down, etc)
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SECTION: 4-2: DEPARTMENTAL CHECKLISTS DATE ISSUED
OR REVISED:
XX-XXX-2007
01-NOV-2004
PURPOSE: To establish a procedure to maintain checklists for Department vehicles
4-2.0 DEPARTMENTAL CHECKLISTS
4-2.1 The Department provides a checklist for both Ambulances and Paramedic
Inventory.
4-2.2 Checklists should be completed at the start of the shiftand placed in the
paperwork drawer.
4-2.3 Missing or below-par levels of equipment or supplies shall be restocked by the
crew.
4-2.4 The Officer On Call shall be notified when any deficiency in supplies or
equipment that cannot be resolved by the crew results in a vehicle being
placed out of service.
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SECTION: 4-3: STANDARD PATIENT RUNFORM DATE ISSUED
OR REVISED:
XX-XXX-2007
01-NOV-2004
PURPOSE: To define the standard procedure to document all requests for service by
Stratford EMS Personnel.
4-3.0 STANDARD PATIENT RUNFORM
4-3.1 Confidentiality
4-3.1.1 All personnel shall be reminded that the patient runform is a
confidential legal document
1 Only the crew that is directly involved in the care of the
patient shall have any information regarding the patient and
the patient�s documentation.
2 Such persons who are involved in the direct care of the patient
may include, but are not limited to, nurses and physicians at
the receiving facility, medical control physicians, Department
administrative personnel, and intercepting paramedics from
outside agencies who assume responsibility for the care of the
patient.
3 Other guidelines regarding privacy may be altered based on
HIPAA guidelines in effect at the time.
4-3.2 Procedures
4-3.2.1 A runform must be completed for every call for service; this
includes
1 All transports
2 RMA�s Refusals of service
3 Cancelled on-scene or en route
4 lift Lift assists
5 Standbys of any type
6 Fire alarm/structure fire calls
7 Walk-ins
8 Any other type of request for assistance where treatment,
advice or assistance is given.
4-3.2.2 The Crew Chief of the unit is responsible to see all paperwork is
completed and turned in; if a Department Paramedic intercepts
with the crew, then the Paramedic becomes responsible for all
paperwork regarding that patient contact. In that situation only
(Department Paramedic intercepting), the crew that was
intercepted with is not required to complete a separate runform.
4-3.2.3 One runform shall be filled out for each patient contact on scene.
1 Special circumstances to consider include, but are not limited
to:
a maternity calls with a childbirth; separate runforms
are to be completed for both mother and child
b in the circumstance of mechanical failure of a vehicle
en route, a runform must be completed from the time
of contact until the patient is handed off to a second
crew.
4-3.2.4 Form completion
1 Use a blue or black ball point pen to complete the form
2 Ensure that writing is legible on all copies
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
3 Complete all patient care information on the front of the form
4 On the rear of the form (or separate form), ensure that all
demographics for the billing portion are complete and a patient
signature is obtained.
4-3.2.5 Provide a copy of the Department�s Statement of Privacy Practices
sheet (per federal HIPAA Guidelines) to all patients where a
runform has been completed.
4-3.3 Supplemental Information
4-3.3.1 In the event additional space is required to document further
narrative, medications administered, and/or to record additional
vitals or EKG strips/notes, the Supplemental Patient Information
Form may be utilized
4-3.4 Distribution
4-3.4.1 Hospital copy
1 This copy is left at the receiving facility in the designated area
2 This copy becomes a permanent part of the patient�s hospital
record.
4-3.4.2 Hospital QA copy
1 This copy is to be left in the designated locked boxes at the
receiving facilities
2 This copy is for review and quality assurance by sponsor
hospital EMS coordinators.
4-3.4.3 Service/billing copies
1 These copies are the Department�s official copies of the
documentation.
2 To ensure patient privacy, copies shall be placed into the slot
of the locked drawer immediately upon return to headquarters.
4-3.5 Sample Form
4-3.5.1 Samples of the Standard Patient Runform and the Supplemental
Patient Information Form are attached on the following pages
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SAMPLE STANDARD PATIENT RUN FORM
STRATFORD EMERGENCY MEDICAL SERVICE C138P1 UNIT # DATE OF SERVICE
/ /
PATIENT LAST NAME FIRST NAME MI AGE DOB SEX M F
CMED #
PATIENT'S HOME ADDRESS CITY/TOWN STATE ZIP ONSET DATE
ONSET TIME
DISPATCH
INCIDENT LOCATION CITY/TOWN STATE ZIP WORK RELATED Y N
SELF-INFLICTED Y N
ENROUTE
PICK UP LOCATION CITY/TOWN STATE ZIP S S N
ON SCENE / INTERCEPT
F.D. FIRST RESPONDER EXTRICATION BY: DEPARTED SCENE PICK UP LOCATION WAS: Street/ Hwy Home Business / Industry Public Place ECF Other __________
DISPATCH ARRIVE
CPR LIFT / MOVE EXTRICATION OTHER ___________
START END
TRAUMA/AGENT OF INJ. VEHICULAR NON-VEHICULAR CAUSES PROTECTIVE DEVICES PPE
ARRIVE HOSP
BACK IN SERVICE Sharp Obj / Knife Blunt Obj / Hard Surf Firearm Fire / Smoke / Heat Toxic Ingestion Other ___________
PATIENT WAS Driver
Passenger
Pedestrian
Other
IN/ON Car Truck/Bus Motorcycle Bicycle Air / Rail / Boat Object
INVOLVED WITH Car Truck/Bus Motorcycle Bicycle Air / Rail / Boat Object.
Medical Assault Fall _______ft Sports Machinery / Tools
Other ____________
Seat /Shoulder Belt Airbag Helmet Goggles Infant/Child Seat Protective Clothing None
Gloves
Mask
Goggles
Gown
Other
TRANSPORT POSITION Supine Prone Head Up Shock L or R Lat Rec Other ____________
EEYYEE OOPPEENNIINNGG 44 SSppoonnttaanneeoouuss
33 TToo VVooiiccee
22 TToo PPaaiinn
11 NNoonnee
VVEERRBBAALL RREESSPPOONNSSEE 55 OOrriieenntteedd 44 CCoonnffuusseedd 33 IInnaapppprroopprriiaattee WWoorrddss 22 IInnccoommpprreehheennssiibbllee SSoouunnddss 11 NNoonnee
MMOOTTOORR RREESSPPOONNSSEE 66 OObbeeyyss CCoommmmaannddss 55 LLooccaalliizzeess PPaaiinn 44 WW iitthhddrraawwss ffrroomm -- PPaaiinn 33 FF lleexxiioonn -- PPaaiinn 22 EExxtteennssiioonn -- PPaaiinn 11 NNoonnee
CAPILLARY REFILL Normal ≤ 2 sec. None Delayed ____sec
PUPILS Equal Unequal R L Reactive Non-Reactive Dilated Constricted Sluggish Blind/Cataracts Prosthetic
SKIN Hot Warm / Dry Cool Diaph. Jaundiced Flushed Cyanotic Pale
LUNG SOUNDS R L Clear Fine Crackles / Rales Course Crackles / Rhonchi Stridor Insp. Wheezes Exp. Wheezes Diminished Absent
ABDOMEN Soft Rigid Distended Obese Tender Non-Tender RUQ LUQ RLQ LLQ
DISPATCHED AS: CHIEF COMPLAINT PATIENT PHYSICIAN
HISTORY OF PRESENT ILLNESS OR INJURY / REMARKS
CURRENT MEDICATIONS ALLERGIES
PAST MEDICAL HISTORY
TIME B/P PULSE (Rate / Quality) RESP (Rate / Quality) GCS LOC SpO2 EtCO2
Total = Regular Irregular
Regular Shallow Labored
E V M A V P U % ON LPM O2 mmhg N / A
Total = Regular Irregular
Regular Shallow Labored
E V M A V P U % ON LPM O2 mmhg N / A
Total = Regular Irregular
Regular Shallow Labored
E V M A V P U % ON LPM O2 mmhg N / A
DDeeff iibb XX JJoouulleess ttoo RRhhyytthhmm ID #
DDeeff iibb XX JJoouulleess ttoo RRhhyytthhmm ID #
DDeeff iibb XX JJoouulleess ttoo RRhhyytthhmm ID #
IV Site 1 L R
IV Site 2 L R
Gauge Fluid Gauge Fluid
ECG
Rate/Amt KVO Rate/Amt KVO ECG Rhythm Interpretation ID # Blood Glucose Initial ____ mg/dL ______time
Blood Glucose Final ____ mg/dL ______time
ID # A S ID # A S ETT Size LMA Size Medication - Route Dose 1 Time Dose 2 Time Dose 3 Time
Depth Medication - Route Dose 1 Time Dose 2 Time Dose 3 Time Priority 1 2 3 Case Disposition Bpt Hosp SVMC Mlfd Hosp Stby Refusal No Pt Diversion Other
Tech Tech Medication - Route Dose 1 Time Dose 2 Time Dose 3 Time
A S A S Medication - Route Dose 1 Time Dose 2 Time Dose 3 Time
Medication - Route Dose 1 Time Dose 2 Time Dose 3 Time
ITEMS LEFT AT FACILITY Canvas Stretcher KED ___ Long Board(s) Short Board Scoop Stretcher Traction Splint, Adult Traction Splint, Pedi
AAiirrwwaayy CCoonnff iirrmm MMeetthhoodd VViissuuaall EEttCCOO22 AAuussccuullttaattee OOtthheerr EEssoopphhaaggeeaall DDeetteeccttoorr DDeevviiccee
Medication - Route Dose 1 Time Dose 2 Time Dose 3 Time
INTERVENTIONS O2 @ _____ LPM via Nebulizer NC NRB Sling / Swath Dressing / Bandage Short Board Long Board Head Blocks (CID) Blanket Rolls C-Collar K.E.D CPR BVM Mouth-to-Mask Traction Splint Cardboard Splint Pillow Splint Irrigation Suction Ice-Pack Reassurance Other Clinical Impression
Physician Signature
ALS Signature
ID #
Crew Chief Name ID # Attendant Name ID # Driver Name ID # Observer Name Signature of Preparer
Date
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SAMPLE SUPPLEMENTAL PATIENT INFORMATION FORM, SIDE A
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
STRATFORD EMERGENCY MEDICAL SERVICE 900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.stratfordems.com
SUPPLEMENTAL
PATIENT
INFORMATION
FORM
SIDE A
INSTRUCTIONS:
This form shall be completed as necessary to provide additional narrative,
medication administration information, and/or EKG and vitals information. A copy
of the completed form may be made at the receiving facility. Submit the original
and copy with the patient run form to the receiving facility and Department
Headquarters.
Patient Name DOB Incident Date Incident Number
Name of Preparer Unit # Incident Time
Signature of Preparer ID #
SUPPLEMENTAL NARRATIVE
SUPPLEMENTAL MEDICATION REPORT
Medication: Time: Dose: Route: ID#
CREW IDs
Crew Chief: EVO: EMT: OBS: Paramedic:
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SAMPLE SUPPLEMENTAL PATIENT INFORMATION FORM, SIDE B
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
STRATFORD EMERGENCY MEDICAL SERVICE 900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.stratfordems.com
SUPPLEMENTAL
PT. INFO
FORM
SIDE B SEE INSTRUCTIONS ON REVERSE, SIDE A
Patient Name DOB Incident Date Incident Number
SUPPLEMENTAL EKG/VITALS
Time: Attach EKG Here/Notes:
B/P: Pulse: R/R: SpO2: Bg: Tx:
Time: Attach EKG Here/Notes:
B/P: Pulse: R/R: SpO2: Bg: Tx:
Time: Attach EKG Here/Notes:
B/P: Pulse: R/R: SpO2: Bg: Tx:
Time: Attach EKG Here/Notes:
B/P: Pulse: R/R: SpO2: Bg: Tx:
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SECTION: 4-4: STATEMENT FORM & POLICY DATE ISSUED
OR REVISED:
XX-XXX-2007
01-NOV-2004
PURPOSE: To define the standard procedure to document all operational issues,
general incidents, unusual occurrences, complaints, and general
statements.
4-4.0 STATEMENT FORM & POLICY
4-4.1 A Departmental Statement form shall be completed whenever appropriate to
document any operational issues, unusual events, incidents, complaints, or
general statements.
4-4.1.1 Statements shall include statements of fact, observations, and/or
documented accounts of events the individual personally
witnessed, heard, etc.
4-4.1.2 Statements and their content shall be considered confidential
Department information
1 Statements and their content shall not be discussed with
anyone other than medical staff at a receiving facility as
directly relates to patient care or an Officer.
2 Statements shall not be copied or otherwise distributed other
than copies for the author or as deemed necessary and
appropriate by the Chief based upon the nature of the
information.
4-4.1.3 Circumstances which require that a Statement form be completed
include, but are not limited to, the following:
1 When directed by any Officer
2 To report actions, activities, or conditions that are related to
the Department and are in violation of this Operations Manual
or any relevant legislation or regulation.
3 Any event which interferes with patient care in any way, such
as equipment malfunction.
4 Any event which interferes or has the potential to interfere
with the normal operations of the Department.
5 Any injury to a patient or bystander that occurs after arrival of
the first Department unit.
6 Any damage to personal property caused by the Department,
such as accidental damage to a patient�s furniture.
4-4.2 Procedure
4-4.2.1 Complete the statement form as soon as possibleprior to the end of
your shift or by the time frame provided by the Officer., whichever
is earlier.
4-4.2.2 Statement forms must have an original signature of the reporting
individual.
4-4.2.3 Unless specifically directed otherwise by an Officer, the form may
be submitted as follows:
1 Hand delivered to any Officer.
2 Placed in the documentation drawer at headquarters.
3 Mailed to Department headquarters at the normal business
address.
4 Electronic submission, such as e-mail, is not accepted
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
4-4.3 Sample Form
4-4.3.1 A Sample of this form is attached on the following page
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SAMPLE STATEMENT FORM
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
STRATFORD EMERGENCY MEDICAL SERVICE 900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.stratfordems.com
STATEMENT
FORM
INSTRUCTIONS:
This form shall be completed as necessary. Provide as much detail as possible. Include
names of witnesses if appropriate. An original signature is required. File completed
forms in the documentation drawer at EMS Headquarters, mail, or hand deliver to any
Officer.
NAME: TITLE/RANK: PAGE OF
DATE OF REPORT: DATE OF INCIDENT: REF. CASE #:
STATEMENT [DOCUMENT WHO, WHAT, WHEN, & WHERE]
SIGNATURES
REPORTED BY DATE
RECEIVED BY (LT OR CAPT SIGNATURE) DATE
RECEIVED BY (CHIEF) DATE
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SECTION: 4-5: OTHER DEPARTMENTAL FORMS DATE ISSUED
OR REVISED:
01-NOV-2004
PURPOSE: To establish the procedure for the use and completion of other
Departmental forms
4-5.0 OTHER DEPARTMENTAL FORMS
4-5.1 The Department shall establish other official forms from time to time as
necessary.
4-5.2 Such additional forms shall be completed per the instructions on or
accompanying the form
OPERATIONS MANUAL
STRATFORD EMERGENCY MEDICAL SERVICE
900 Longbrook Avenue Stratford, CT 06614 (203) 385-4060
http://www.townofstratford.com/ems
OPERATIONS MANUAL - Final Draft Revisions as of 13-Aug-2007
SECTION: 4-6: OTHER NON-DEPARTMENTAL FORMS DATE ISSUED
OR REVISED:
01-NOV-2004
PURPOSE: To establish the procedure for the use and completion of other, non-
Departmental forms
4-6.0 OTHER NON-DEPARTMENTAL FORMS
4-6.1 The Department completes and/or receives other, official forms of other
agencies from time to time during the normal course of business which are not
specifically addressed in this Department Operations Manual.
4-6.2 Such forms include, but are not limited to:
4-6.2.1 State Department of Mental Health Police Emergency Examination
Request
1 This report is completed by a Police Officer and provided to the
crew or receiving medical facility.
2 A copy of the completed form should be retained by the crew
and placed with the patient paperwork lock box at Department
headquarters.
3 Ensure that the original is provided to the receiving medical
facility.
4-6.2.2 JHPC Paramedic Preceptor Call Evaluation Form
1 This form is completed by a paramedic preceptor to provide an
evaluation of skills of a paramedic student or precepting
paramedic.
4-6.3 Completion of all non-Departmental forms should be carried out as necessary
according to the instructions on or accompanying the form.