operations manual stratford emergency...

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.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



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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)



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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.


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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


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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


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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







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





SAMPLE SUPPLEMENTAL PATIENT INFORMATION FORM, SIDE A


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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:



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SAMPLE SUPPLEMENTAL PATIENT INFORMATION FORM, SIDE B


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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:









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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


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4-4.3 Sample Form

4-4.3.1 A Sample of this form is attached on the following page


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SAMPLE STATEMENT FORM


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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



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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


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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.


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