Patient Care Form EAS "*" indicates required fields Step 1 of 4 - PATIENT'S INFORMATION AND INCIDENT DETAILS 25% PATIENT'S INFORMATION AND INCIDENT DETAILSPatient Name* Patient IC/FIN/Passport Number* Gender*Please ChooseMaleFemaleRace*Please ChooseChineseMalayIndianEurasianOtherOther Race* Date of Birth* DD slash MM slash YYYY Age* Patient Address*Postal Code* Contact Number* Incident Address*Date of Incident* DD slash MM slash YYYY Incident Number* Vehicle Licence Plate Number* Condition* Medical Trauma Handover to SCDF Cancelled Other Please State* CHIEF COMPLAINT AND EVENTS SURROUNDING*PAST MEDICAL HISTORY* No Unknown Heart Disease Hypertension Hyperlipidemia Renal Disease Asthma/COPD Cancer Other Please Specify Past Medical History* Please Specify Cancer Site* PATIENT MEDICATIONS* Nil Yes Please Specify Patient Medications* ALLERGIES* No Unknown Yes Please Specify Allergies* PATIENT'S ASSESSMENTCERVICAL SPINE INJURY* Yes No AIRWAY* Clear Obstructed BREATHING* Spontaneous Rapid Slow Laboured Absent CIRCULATION* Regular Rapid Slow Absent SKIN COLOUR AND CONDITIONS* Normal Pale Cyanotic Flushed Jaundice Cool Cold Warm Dry Diaphoretic CONSCIOUS LEVEL* Alert Verbal Pain Unresponsive CAPILARRY REFILL* Normal Delayed None PupilsNormal Left Right Constricted Left Right Dilated Left Right No reaction Left Right VITAL SIGNS AND GLASCOW COMA SCALE (GCS)Vital 1Time* Hours : Minutes BLOOD PRESSURE* PULSE* RESP* SPO2* EtCO2* TOTAL GCS* Vital 2Time Hours : Minutes BLOOD PRESSURE PULSE RESP SPO2 EtCO2 TOTAL GCS Vital 3Time Hours : Minutes BLOOD PRESSURE PULSE RESP SPO2 EtCO2 TOTAL GCS Hypocount: Temperature: MEDICATIONS ADMINISTEREDTime* Hours : Minutes DRUGS/INFUSION* DOSAGE* Time Hours : Minutes DRUGS/INFUSION DOSAGE Time Hours : Minutes DRUGS/INFUSION DOSAGE Time Hours : Minutes DRUGS/INFUSION DOSAGE PROCEDURESAIRWAY INSERTION* OPA ETT LMA King LT Other SUCTION* Yes No Please Specify Other Airway Insertion* OXYGEN GIVEN* By* Nebuliser Fask Mask Nasal Cannula Non Rebreathing Face Mask with Intravenous Bandaging Splints Reservoir Bag Valve Mask Other Please Specify Other Oxygen Given Method* CARDIAC MONITOR* Yes No INTRAVENOUS* Intravenous Intraosseous IMMOBILISATION* Cervical collar Head Immobiliser Long Backboard Scoop KED Bandaging Splints Other Please Specify Other Immobilisation* ANY OTHER TREATMENT GIVEN*CARDIAC ARREST* Yes No If Yes, please submit EMERGENCY AMBULANCE HEART SAVE FORMAcronyms: OPA-Oropharyngeal Airway, LMA-Laryngeal Mask Airway, ETT-Endotracheal Tube King, LT-King Laryngeal Tube, KED-Kendrick Extrication Device.EMERGENCY AMBULANCE CREW DETAILSCrew Leader* IC/FIN Number* Assistant* IC/FIN Number* Driver* IC/FIN Number* CASE TRANSFERRED TOReceiving Hospital/Agency Name:* Signature of Crew Leader*GSC SCORE CHARTEYE OPENING 4 - Spontaneous 3 - To Voice 2 - To Pain 1 - NoneVERBAL 5 - Orientated (Smiles, interacts) 4 - Confused (Cries but consolable) 3 - Inappr words (moaning, unconsolable) 2 - Incompr words (inconsolable, agitated) 1 - None (No verbal response) MOTOR RESPONSE (PEDIATRIC) 6 - Obeys Command (Moves spontaneously) 5 - Localised Pain (Withdraws from touch) 4 - Withdrawal Pain (Withdraws from pain) 3 - Flexion Pain (Abnormal flexion to pain) 2 - Extension Pain (Extension to pain) 1 - None (No motor response) EMERGENCY AMBULANCE HEART SAVE RECORDINCIDENT INFORMATIONCondition* Cardiac Arrest Post Cardiac Arrest Incident No.* Message Received*ID of Crew Leader* Vehicle Licence Plate Number* PATIENT INFORMATIONID Type* NRIC Passport FIN Hospital Registration Others ID Number* FIRST RESPONDERName of First Responder* Time First Responder arrived at patient’s side* Hours : Minutes Shock by First Responder* Yes No No. of shock(s)* EVENTSPlace of Collapse* Home Residence Healthcare facility Street/Highway Nursing home Public/Commercial building Industrial place Place of recreation Transport centre In ambulance Others Please Specify:* Estimated Time of collapse* Hours : Minutes Cause of Arrest* Trauma Non-Trauma Collapse witnessed by* Bystander Responding Crew No witness Bystander* Healthcare Lay Person Family Responding Crew* Ambulance Crew MTS Crew Dispatched-Assisted CPR* Yes No Bystander CPR* Yes No Yes* Compression Ventilation Bystander AED* Yes No Bystander Defibrillation* Yes No No. of shock(s)* Activity prior to cardiac arrest* Exercise/Sports (w/i 1hr of exercise) At work Activities of Daily Living Resting/Sleeping Others Please Specify:* Past Medical History* Yes (Please fill in Patient Care Form past medical history field) No Unknown Problem extricating/transferring patient* Yes, why? No Yes, why?* Delay by Family/ Bystander Trapped/Rescue required Confined space @ Scene Bariatric Patient No Lift/ Lift faulty Others Please Specify:* RESUSCITATION BY AMBULANCE CREWInitial StatusBreathing* Yes No Pulse* Yes No CPR Attempted* Yes No, CPR, not attempted Time manual CPR started* Hours : Minutes Time AED applied* Hours : Minutes Handover case to SCDF* Yes No Time* Hours : Minutes *Mechanical CPR device used (if any)* Yes No Time Hours : Minutes AM PM AM/PM Please tick the reasons below* Not possible to position LUCAS safely Mechanical fault Patient too big Chest Injuries Patient too small ROSC Others Please Specify:* Advance Airway device attempted* Yes No Attempted but unsuccessful Time attempted* Hours : Minutes Please select* LMA Laryngeal tube Others Please Specify:* Size of Airway inserted* Time inserted successfully* Hours : Minutes Please tick the reason below* Severe Maxilofacial Injuries Spontaneous Breathing Trismus Why?* Stomach content regurgitation Foreign Body Too much Blood Others Please Specify:* Final Route of Drug Administration* IV IO No IV/IO Time IV 1st attempted* Hours : Minutes No. of Attempts* Time IV/IO successfully inserted* Hours : Minutes Please tick reason* IV by Healthcare Staff at Scene No IO in Ambulance Others Please Specify:* Drug Key: AD- Adrenaline, NS - Sodium Chloride, DT - Dextrose, OT - Others,S/N 1Drugs Given Dosage Time Given Hours : Minutes S/N 2Drugs Given Dosage Time Given Hours : Minutes S/N 3Drugs Given Dosage Time Given Hours : Minutes S/N 4Drugs Given Dosage Time Given Hours : Minutes S/N 5Drugs Given Dosage Time Given Hours : Minutes S/N 6Drugs Given Dosage Time Given Hours : Minutes S/N 7Drugs Given Dosage Time Given Hours : Minutes S/N 8Drugs Given Dosage Time Given Hours : Minutes S/N 9Drugs Given Dosage Time Given Hours : Minutes S/N 10Drugs Given Dosage Time Given Hours : Minutes Rhythm Key: 01 - VF, 02 - Pulseless VT, 03 - Pulseless Electrical Activity, 04 - Asystole, 05 - Sinus / other perfusing rhythmPresenting rhythm* Rhythm on arrival at ED* # 1Energy (joules)* Time of Shock* Hours : Minutes Rhythm Key Before Shock* RETURN OF SPONTANEOUS CIRCULATION (ROSC)* Yes No Time of 1st ROSC* Hours : Minutes POST RESUSCITATION MONITORING (Tick all applicable boxes)* 12 leads ECG ETCo2 ETCo2 Reading:* Pronounced dead before Ambulance departure from ED?* Yes No Time of Pronounced Dead* Hours : Minutes Signature of crew leader completing report*