EMSDataSet
-
Root Tag For Patient Care Report Dataset |
|
Header
-
Header for file |
|
DemographicGroup
-
Demographic information related to this agency |
|
dAgency.01
-
EMS Agency Unique State ID EMS Agency Unique State ID |
A078 |
dAgency.02
-
EMS Agency Number EMS Agency Number |
350-A078 |
dAgency.04
-
EMS Agency State EMS Agency State |
Colorado |
PatientCareReport
-
Container Tag to hold each instance of a patient care report (PCR) |
[UUID
=
[Your UUID]]
|
eRecord
-
Patient Record Information |
|
eRecord.01
-
Patient Care Report Number |
[Your Patient Care Report Number]
|
eRecord.SoftwareApplicationGroup
-
Group Tag to hold information about the software used to generate this patient care report |
|
eRecord.02
-
Software Creator |
[Your Software Creator]
|
eRecord.03
-
Software Name |
[Your Software Name]
|
eRecord.04
-
Software Version |
[Your Software Version]
|
eResponse
-
Unit Agency Information |
|
eResponse.AgencyGroup
-
Group Tag to hold EMS agency number and name |
|
eResponse.01
-
EMS Agency Number |
350-A078 |
eResponse.02
-
EMS Agency Name |
[Value from DEMDataSet]
|
eResponse.03
-
Incident Number |
350-2024-EMS1 |
eResponse.04
-
EMS Response Number |
350-2024-EMS1-1 |
eResponse.ServiceGroup
-
Group Tag to hold details about EMS category of service and the stand by reason |
|
eResponse.05
-
Type of Service Requested |
Emergency Response (Primary Response Area) |
eResponse.07
-
Unit Transport and Equipment Capability |
Ground Transport (ALS Equipped) |
eResponse.08
-
Type of Dispatch Delay |
None/No Delay |
eResponse.09
-
Type of Response Delay |
None/No Delay |
eResponse.10
-
Type of Scene Delay |
Safety-Crew/Staging |
eResponse.11
-
Type of Transport Delay |
[NV
=
Not Applicable] |
eResponse.12
-
Type of Turn-Around Delay |
Clean-up |
eResponse.13
-
EMS Vehicle (Unit) Number |
G194 |
eResponse.14
-
EMS Unit Call Sign |
Medic 1 |
eResponse.16
-
Vehicle Dispatch Location |
Poudre Valley Hospital Office |
eResponse.17
-
Vehicle Dispatch GPS Location |
40.572568,-105.057274 |
eResponse.18
-
Vehicle Dispatch Location US National Grid Coordinates |
13TDE95159131 |
eResponse.19
-
Beginning Odometer Reading of Responding Vehicle |
341002.5 |
eResponse.20
-
On-Scene Odometer Reading of Responding Vehicle |
341007.4 |
eResponse.22
-
Ending Odometer Reading of Responding Vehicle |
341012.6 |
eResponse.23
-
Response Mode to Scene |
Non-Emergent |
eResponse.24
-
Additional Response Mode Descriptors |
No Lights or Sirens |
eDispatch
-
Dispatch Information |
|
eDispatch.01
-
Dispatch Reason |
Sick Person |
eDispatch.02
-
EMD Performed |
No |
eDispatch.03
-
EMD Card Number |
26A4 |
eDispatch.04
-
Dispatch Center Name or ID |
Fort Collins 911 |
eDispatch.05
-
Dispatch Priority (Patient Acuity) |
Lower Acuity |
eDispatch.06
-
Unit Dispatched CAD Record ID |
202308357 |
eCrew
-
Crew Member Information |
|
eCrew.CrewGroup
-
Group Tag to hold crew information |
|
eCrew.01
-
Crew Member ID |
455258 - Declan Collin Renner |
eCrew.02
-
Crew Member Level |
Paramedic |
eCrew.03
-
Crew Member Response Role |
Primary Patient Caregiver-At Scene |
eCrew.CrewGroup
-
Group Tag to hold crew information |
|
eCrew.01
-
Crew Member ID |
653148 - Sabryna Charlotte Braun |
eCrew.02
-
Crew Member Level |
Emergency Medical Responder (EMR) |
eCrew.03
-
Crew Member Response Role |
Driver/Pilot-Response |
Other Patient Caregiver-At Scene |
eTimes
-
Call Event Times Information |
|
eTimes.01
-
PSAP Call Date/Time |
October 4, 2023, 10:08:38 GMT-06:00 |
eTimes.02
-
Dispatch Notified Date/Time |
October 4, 2023, 10:08:38 GMT-06:00 |
eTimes.03
-
Unit Notified by Dispatch Date/Time |
October 4, 2023, 10:09:47 GMT-06:00 |
eTimes.04
-
Dispatch Acknowledged Date/Time |
October 4, 2023, 10:09:58 GMT-06:00 |
eTimes.05
-
Unit En Route Date/Time |
October 4, 2023, 10:11:14 GMT-06:00 |
eTimes.06
-
Unit Arrived on Scene Date/Time |
October 4, 2023, 10:26:20 GMT-06:00 |
eTimes.07
-
Arrived at Patient Date/Time |
October 4, 2023, 10:29:53 GMT-06:00 |
eTimes.08
-
Transfer of EMS Patient Care Date/Time |
[NV
=
Not Applicable] |
eTimes.09
-
Unit Left Scene Date/Time |
October 4, 2023, 10:42:01 GMT-06:00 |
eTimes.11
-
Patient Arrived at Destination Date/Time |
[NV
=
Not Applicable] |
eTimes.12
-
Destination Patient Transfer of Care Date/Time |
[NV
=
Not Applicable] |
eTimes.13
-
Unit Back in Service Date/Time |
October 4, 2023, 11:02:31 GMT-06:00 |
eTimes.15
-
Unit Back at Home Location Date/Time |
October 4, 2023, 10:57:46 GMT-06:00 |
eTimes.16
-
EMS Call Completed Date/Time |
October 4, 2023, 11:05:23 GMT-06:00 |
ePatient
-
Patient Information |
|
ePatient.01
-
EMS Patient ID |
67gh7321 |
ePatient.PatientNameGroup
-
Group Tag to hold patient's name |
|
ePatient.02
-
Last Name |
Tremblay |
ePatient.03
-
First Name |
Josue |
ePatient.05
-
Patient's Home Address |
2521 Milton Lane |
ePatient.06
-
Patient's Home City |
City of Fort Collins |
ePatient.07
-
Patient's Home County |
Larimer County |
ePatient.08
-
Patient's Home State |
Colorado |
ePatient.09
-
Patient's Home ZIP Code |
80549 |
ePatient.10
-
Patient's Country of Residence |
US |
ePatient.11
-
Patient Home Census Tract |
08069001308 |
ePatient.12
-
Social Security Number |
778628144 |
ePatient.13
-
Gender |
Female-to-Male, Transgender Male |
ePatient.14
-
Race |
Hispanic or Latino |
White |
ePatient.AgeGroup
-
Group Tag to hold patient's age information |
|
ePatient.15
-
Age |
41 |
ePatient.16
-
Age Units |
Years |
ePatient.17
-
Date of Birth |
March 29, 1982 |
ePatient.18
-
Patient's Phone Number |
[PN
=
Unable to Complete] |
ePayment
-
Insurance/Payment Information |
|
ePayment.01
-
Primary Method of Payment |
Not Billed (for any reason) |
ePayment.08
-
Patient Resides in Service Area |
Resident Within EMS Service Area |
ePayment.50
-
CMS Service Level |
[NV
=
Not Recorded] |
ePayment.SupplyItemGroup
-
Group Tag to hold information about the supply used on the patient by the EMS Crew during the EMS event. |
|
ePayment.55
-
Supply Item Used Name |
Surgical Mask |
ePayment.56
-
Number of Supply Item(s) Used |
2 |
eScene
-
Incident Scene Information |
|
eScene.01
-
First EMS Unit on Scene |
[NV
=
Not Applicable] |
eScene.06
-
Number of Patients at Scene |
Single |
eScene.07
-
Mass Casualty Incident |
No |
eScene.08
-
Triage Classification for MCI Patient |
[NV
=
Not Applicable] |
eScene.09
-
Incident Location Type |
Y92.0 - Non-institutional (private) residence as the place of occurrence of the external cause |
eScene.10
-
Incident Facility Code |
[NV
=
Not Applicable] |
eScene.11
-
Scene GPS Location |
40.622528,-105.033253 |
eScene.12
-
Scene US National Grid Coordinates |
13TDE97189685 |
eScene.15
-
Incident Street Address |
2521 Milton Lane |
eScene.17
-
Incident City |
City of Fort Collins |
eScene.18
-
Incident State |
Colorado |
eScene.19
-
Incident ZIP Code |
80549 |
eScene.21
-
Incident County |
Larimer County |
eScene.22
-
Incident Country |
US |
eScene.23
-
Incident Census Tract |
08069001308 |
eSituation
-
Situation Information |
|
eSituation.01
-
Date/Time of Symptom Onset |
October 3, 2023, 11:30:00 GMT-06:00 |
eSituation.02
-
Possible Injury |
No |
eSituation.PatientComplaintGroup
-
Group Tag to hold information about patient's complaint |
|
eSituation.03
-
Complaint Type |
Chief (Primary) |
eSituation.04
-
Complaint |
Fever |
eSituation.05
-
Duration of Complaint |
1 |
eSituation.06
-
Time Units of Duration of Complaint |
Days |
eSituation.PatientComplaintGroup
-
Group Tag to hold information about patient's complaint |
|
eSituation.03
-
Complaint Type |
Secondary |
eSituation.04
-
Complaint |
Dizziness |
eSituation.05
-
Duration of Complaint |
2 |
eSituation.06
-
Time Units of Duration of Complaint |
Hours |
eSituation.07
-
Chief Complaint Anatomic Location |
General/Global |
eSituation.08
-
Chief Complaint Organ System |
Global/General |
eSituation.09
-
Primary Symptom |
R50.9 - Fever, unspecified |
eSituation.10
-
Other Associated Symptoms |
R05 - Cough |
[PN
=
Symptom Not Present] R06.00 - Dyspnea, unspecified |
[PN
=
Symptom Not Present] R06.02 - Shortness of breath |
[PN
=
Symptom Not Present] R06.2 - Wheezing |
R42 - Dizziness and giddiness |
R53.83 - Other fatigue |
eSituation.11
-
Provider's Primary Impression |
B99.9 - Unspecified infectious disease |
eSituation.12
-
Provider's Secondary Impressions |
[NV
=
Not Recorded] |
eSituation.13
-
Initial Patient Acuity |
Lower Acuity (Green) |
eSituation.WorkRelatedGroup
-
Group Tag to hold patient details if the illness or injury is work related |
|
eSituation.14
-
Work-Related Illness/Injury |
No |
eSituation.18
-
Date/Time Last Known Well |
October 2, 2023, 22:00:00 GMT-06:00 |
eSituation.20
-
Reason for Interfacility Transfer/Medical Transport |
[NV
=
Not Applicable] |
eInjury
-
Injury Information |
|
eInjury.01
-
Cause of Injury |
[NV
=
Not Applicable] |
eInjury.02
-
Mechanism of Injury |
[NV
=
Not Applicable] |
eInjury.03
-
Trauma Triage Criteria (High Risk for Serious Injury) |
[NV
=
Not Applicable] |
eInjury.04
-
Trauma Triage Criteria (Moderate Risk for Serious Injury) |
[NV
=
Not Applicable] |
eArrest
-
Cardiac Arrest Information |
|
eArrest.01
-
Cardiac Arrest |
No |
eArrest.02
-
Cardiac Arrest Etiology |
[NV
=
Not Applicable] |
eArrest.03
-
Resuscitation Attempted By EMS |
[NV
=
Not Applicable] |
eArrest.04
-
Arrest Witnessed By |
[NV
=
Not Applicable] |
eArrest.07
-
AED Use Prior to EMS Arrival |
[NV
=
Not Applicable] |
eArrest.09
-
Type of CPR Provided |
[NV
=
Not Applicable] |
eArrest.11
-
First Monitored Arrest Rhythm of the Patient |
[NV
=
Not Applicable] |
eArrest.12
-
Any Return of Spontaneous Circulation |
[NV
=
Not Applicable] |
eArrest.14
-
Date/Time of Cardiac Arrest |
[NV
=
Not Applicable] |
eArrest.16
-
Reason CPR/Resuscitation Discontinued |
[NV
=
Not Applicable] |
eArrest.17
-
Cardiac Rhythm on Arrival at Destination |
[NV
=
Not Applicable] |
eArrest.18
-
End of EMS Cardiac Arrest Event |
[NV
=
Not Applicable] |
eArrest.20
-
Who First Initiated CPR |
[NV
=
Not Applicable] |
eArrest.21
-
Who First Applied the AED |
[NV
=
Not Applicable] |
eArrest.22
-
Who First Defibrillated the Patient |
[NV
=
Not Applicable] |
eHistory
-
Patient History Information |
|
eHistory.01
-
Barriers to Patient Care |
None Noted |
eHistory.06
-
Medication Allergies |
[PN
=
Unable to Complete] |
eHistory.08
-
Medical/Surgical History |
J40 - Bronchitis, not specified as acute or chronic |
J45.30 - Mild persistent asthma, uncomplicated |
eHistory.09
-
Medical History Obtained From |
Patient |
eHistory.ImmunizationsGroup
-
Group Tag to hold Immunization type and date |
|
eHistory.10
-
The Patient's Type of Immunization |
[PN
=
Not Immunized] [Custom Value] COVID-19 |
eHistory.CurrentMedsGroup
-
Group Tag to hold info about patient's medication |
|
eHistory.12
-
Current Medications |
10368 - terbutaline |
eHistory.13
-
Current Medication Dose |
1 |
eHistory.14
-
Current Medication Dosage Unit |
Puffs |
eHistory.15
-
Current Medication Administration Route |
Inhalation |
eHistory.20
-
Current Medication Frequency |
prn (as needed) |
eHistory.17
-
Alcohol/Drug Use Indicators |
[PN
=
None Reported] |
eHistory.19
-
Last Oral Intake |
October 3, 2023, 19:00:00 GMT-06:00 |
eNarrative
-
Call Event Narrative |
|
eNarrative.01
-
Patient Care Report Narrative |
Patient has had a fever since yesterday. He is worried about COVID, since he has asthma and recently had bronchitis. We found no respiratory issues and did not recommend transport to the hospital. |
eVitals
-
Patient Vital Sign Information |
|
eVitals.VitalGroup
-
Group Tag to hold eVitals information |
|
eVitals.01
-
Date/Time Vital Signs Taken |
October 4, 2023, 10:33:00 GMT-06:00 |
eVitals.02
-
Obtained Prior to this Unit's EMS Care |
No |
eVitals.CardiacRhythmGroup
-
Group Tag to hold information of the type and method used for ECG interpretation associated with the cardiac rhythm. |
|
eVitals.03
-
Cardiac Rhythm / Electrocardiography (ECG) |
[NV
=
Not Recorded] |
eVitals.04
-
ECG Type |
[NV
=
Not Recorded] |
eVitals.05
-
Method of ECG Interpretation |
[NV
=
Not Recorded] |
eVitals.BloodPressureGroup
-
Group Tag to hold the details of patient's blood pressure. |
|
eVitals.06
-
SBP (Systolic Blood Pressure) |
132 |
eVitals.07
-
DBP (Diastolic Blood Pressure) |
85 |
eVitals.08
-
Method of Blood Pressure Measurement |
Cuff-Automated |
eVitals.HeartRateGroup
-
Group Tag to hold the details of patient's heart rate. |
|
eVitals.10
-
Heart Rate |
72 |
eVitals.11
-
Method of Heart Rate Measurement |
Palpated |
eVitals.12
-
Pulse Oximetry |
97 |
eVitals.14
-
Respiratory Rate |
18 |
eVitals.15
-
Respiratory Effort |
Normal |
eVitals.16
-
End Tidal Carbon Dioxide (ETCO2) |
[NV
=
Not Recorded] |
eVitals.18
-
Blood Glucose Level |
[PN
=
Refused] |
eVitals.GlasgowScoreGroup
-
Group Tag to hold the details of patient's glasgow scale |
|
eVitals.19
-
Glasgow Coma Score-Eye |
4 -
Opens Eyes spontaneously (All Age Groups) |
eVitals.20
-
Glasgow Coma Score-Verbal |
5 -
Oriented (>2 Years); Smiles, oriented to sounds, follows objects, interacts |
eVitals.21
-
Glasgow Coma Score-Motor |
6 -
Obeys commands (>2Years); Appropriate response to stimulation |
eVitals.22
-
Glasgow Coma Score-Qualifier |
Initial GCS has legitimate values without interventions such as intubation and sedation |
eVitals.23
-
Total Glasgow Coma Score |
15 |
eVitals.TemperatureGroup
-
Group Tag to hold information about patient's body temperature. |
|
eVitals.24
-
Temperature |
38.7 |
eVitals.25
-
Temperature Method |
Oral |
eVitals.26
-
Level of Responsiveness (AVPU) |
Alert |
eVitals.PainScaleGroup
-
Group Tag to hold the scale of patient's pain and the type of pain scale used. |
|
eVitals.27
-
Pain Scale Score |
[NV
=
Not Recorded] |
eVitals.StrokeScaleGroup
-
Group Tag to hold the results of patient's stroke scale and the type of stroke pain scale used. |
|
eVitals.29
-
Stroke Scale Score |
Negative |
eVitals.30
-
Stroke Scale Type |
Rapid Arterial oCclusion Evaluation (RACE) |
eVitals.31
-
Reperfusion Checklist |
[NV
=
Not Recorded] |
eExam
-
Patient Exam Information |
|
eExam.01
-
Estimated Body Weight in Kilograms |
66.5 |
eExam.AssessmentGroup
-
Group Tag to hold assessment information |
|
eExam.03
-
Date/Time of Assessment |
October 4, 2023, 10:35:00 GMT-06:00 |
eExam.LungGroup
-
Group Tag to hold lung assessment findings information |
|
eExam.22
-
Lung Assessment Finding Location |
Bilateral |
eExam.23
-
Lung Assessment |
Breath Sounds-Equal |
Breath Sounds-Normal |
[PN
=
Exam Finding Not Present] Rales |
[PN
=
Exam Finding Not Present] Stridor |
[PN
=
Exam Finding Not Present] Wheezing-Expiratory |
[PN
=
Exam Finding Not Present] Wheezing-Inspiratory |
eExam.19
-
Mental Status Assessment |
Normal Baseline for Patient |
eExam.20
-
Neurological Assessment |
Normal Baseline for Patient |
eProtocols
-
Medical Protocols Information |
|
eProtocols.ProtocolGroup
-
Group Tag to hold eProtocol information |
|
eProtocols.01
-
Protocols Used |
General-Fever |
eProtocols.02
-
Protocol Age Category |
General |
eProtocols.ProtocolGroup
-
Group Tag to hold eProtocol information |
|
eProtocols.01
-
Protocols Used |
Medical-Influenza-Like Illness/ Upper Respiratory Infection |
eProtocols.02
-
Protocol Age Category |
General |
eMedications
-
Intervention Medications Information |
|
eMedications.MedicationGroup
-
Group Tag to hold eMedication information |
|
eMedications.01
-
Date/Time Medication Administered |
[NV
=
Not Recorded] |
eMedications.02
-
Medication Administered Prior to this Unit's EMS Care |
[NV
=
Not Recorded] |
eMedications.03
-
Medication Administered |
[NV
=
Not Recorded] |
eMedications.04
-
Medication Administered Route |
[NV
=
Not Recorded] |
eMedications.DosageGroup
-
Group Tag to hold info about the medication dosage administered to the patient |
|
eMedications.05
-
Medication Dosage |
[NV
=
Not Recorded] |
eMedications.06
-
Medication Dosage Units |
[NV
=
Not Recorded] |
eMedications.07
-
Response to Medication |
[NV
=
Not Recorded] |
eMedications.08
-
Medication Complication |
[NV
=
Not Recorded] |
eMedications.10
-
Role/Type of Person Administering Medication |
[NV
=
Not Recorded] |
eProcedures
-
Intervention Procedures Information |
|
eProcedures.ProcedureGroup
-
Group Tag to hold eProcedures information |
|
eProcedures.01
-
Date/Time Procedure Performed |
[NV
=
Not Recorded] |
eProcedures.02
-
Procedure Performed Prior to this Unit's EMS Care |
[NV
=
Not Recorded] |
eProcedures.03
-
Procedure |
[NV
=
Not Recorded] |
eProcedures.05
-
Number of Procedure Attempts |
[NV
=
Not Recorded] |
eProcedures.06
-
Procedure Successful |
[NV
=
Not Recorded] |
eProcedures.07
-
Procedure Complication |
[NV
=
Not Recorded] |
eProcedures.08
-
Response to Procedure |
[NV
=
Not Recorded] |
eProcedures.10
-
Role/Type of Person Performing the Procedure |
[NV
=
Not Recorded] |
eDisposition
-
Patient Disposition Information |
|
eDisposition.DestinationGroup
-
Group Tag to hold info about the Destination and the Disposition details |
|
eDisposition.01
-
Destination/Transferred To, Name |
[NV
=
Not Applicable] |
eDisposition.02
-
Destination/Transferred To, Code |
[NV
=
Not Applicable] |
eDisposition.05
-
Destination State |
[NV
=
Not Applicable] |
eDisposition.06
-
Destination County |
[NV
=
Not Applicable] |
eDisposition.07
-
Destination ZIP Code |
[NV
=
Not Applicable] |
eDisposition.11
-
Number of Patients Transported in this EMS Unit |
[NV
=
Not Applicable] |
eDisposition.IncidentDispositionGroup
-
Group Tag to hold info about the incident disposition details |
|
eDisposition.27
-
Unit Disposition |
Patient Contact Made |
eDisposition.28
-
Patient Evaluation/Care |
Patient Evaluated, No Care Required |
eDisposition.29
-
Crew Disposition |
Back in Service, No Care/Support Services Required |
eDisposition.30
-
Transport Disposition |
No Transport |
eDisposition.31
-
Reason for Refusal/Release |
Released Following Protocol Guidelines |
eDisposition.16
-
EMS Transport Method |
[NV
=
Not Applicable] |
eDisposition.17
-
Transport Mode from Scene |
[NV
=
Not Recorded] |
eDisposition.18
-
Additional Transport Mode Descriptors |
[NV
=
Not Recorded] |
eDisposition.19
-
Final Patient Acuity |
Lower Acuity (Green) |
eDisposition.20
-
Reason for Choosing Destination |
[NV
=
Not Applicable] |
eDisposition.21
-
Type of Destination |
[NV
=
Not Applicable] |
eDisposition.22
-
Hospital In-Patient Destination |
[NV
=
Not Applicable] |
eDisposition.23
-
Hospital Capability |
[NV
=
Not Applicable] |
eDisposition.HospitalTeamActivationGroup
-
Group Tag to hold info about the destination team pre-arrival activation |
|
eDisposition.24
-
Destination Team Pre-Arrival Alert or Activation |
[NV
=
Not Applicable] |
eDisposition.25
-
Date/Time of Destination Prearrival Alert or Activation |
[NV
=
Not Applicable] |
eDisposition.26
-
Disposition Instructions Provided |
Contact 911 or see your Doctor if problem worsens |
eDisposition.32
-
Level of Care Provided per Protocol |
[NV
=
Not Applicable] |
eOutcome
-
Patient Outcome Information |
|
eOutcome.01
-
Emergency Department Disposition |
[NV
=
Not Applicable] |
eOutcome.02
-
Hospital Disposition |
[NV
=
Not Applicable] |
eOutcome.EmergencyDepartmentProceduresGroup
-
Group Tag to hold information about emergency department procedures |
|
eOutcome.09
-
Emergency Department Procedures |
[NV
=
Not Applicable] |
eOutcome.19
-
Date/Time Emergency Department Procedure Performed |
[NV
=
Not Applicable] |
eOutcome.10
-
Emergency Department Diagnosis |
[NV
=
Not Applicable] |
eOutcome.11
-
Date/Time of Hospital Admission |
[NV
=
Not Applicable] |
eOutcome.HospitalProceduresGroup
-
Group Tag to hold information about hospital procedures |
|
eOutcome.12
-
Hospital Procedures |
[NV
=
Not Applicable] |
eOutcome.20
-
Date/Time Hospital Procedure Performed |
[NV
=
Not Applicable] |
eOutcome.13
-
Hospital Diagnosis |
[NV
=
Not Applicable] |
eOutcome.16
-
Date/Time of Hospital Discharge |
[NV
=
Not Applicable] |
eOutcome.18
-
Date/Time of Emergency Department Admission |
[NV
=
Not Applicable] |
eOther
-
Other Miscellaneous Information |
|
eOther.01
-
Review Requested |
No |
eOther.EMSCrewMemberGroup
-
Group Tag to hold info about the EMS Crew Member |
|
eOther.03
-
Personal Protective Equipment Used |
Gloves |
Mask-Surgical (Non-Fitted) |
eOther.04
-
EMS Professional (Crew Member) ID |
455258 - Declan Collin Renner |
eOther.05
-
Suspected EMS Work Related Exposure, Injury, or Death |
No |
eOther.06
-
The Type of Work-Related Injury, Death or Suspected Exposure |
None |
eOther.EMSCrewMemberGroup
-
Group Tag to hold info about the EMS Crew Member |
|
eOther.03
-
Personal Protective Equipment Used |
Gloves |
Mask-Surgical (Non-Fitted) |
eOther.04
-
EMS Professional (Crew Member) ID |
653148 - Sabryna Charlotte Braun |
eOther.05
-
Suspected EMS Work Related Exposure, Injury, or Death |
No |
eOther.06
-
The Type of Work-Related Injury, Death or Suspected Exposure |
None |
eOther.08
-
Crew Member Completing this Report |
653148 - Sabryna Charlotte Braun |
eOther.SignatureGroup
-
Group Tag to hold signature details |
|
eOther.12
-
Type of Person Signing |
EMS Crew Member (Other) |
eOther.13
-
Signature Reason |
Other |
eOther.15
-
Signature Status |
Signed |
eOther.19
-
Date/Time of Signature |
October 4, 2023, 11:00:05 GMT-06:00 |
eOther.20
-
Signature Last Name |
Braun |
eOther.21
-
Signature First Name |
Sabryna |
eOther.SignatureGroup
-
Group Tag to hold signature details |
|
eOther.12
-
Type of Person Signing |
EMS Primary Care Provider (for this event) |
eOther.13
-
Signature Reason |
Other |
eOther.15
-
Signature Status |
Signed |
eOther.19
-
Date/Time of Signature |
October 4, 2023, 11:00:43 GMT-06:00 |
eOther.20
-
Signature Last Name |
Renner |
eOther.21
-
Signature First Name |
Declan |
eOther.SignatureGroup
-
Group Tag to hold signature details |
|
eOther.12
-
Type of Person Signing |
Patient |
eOther.13
-
Signature Reason |
HIPAA acknowledgement/Release |
Other |
eOther.14
-
Type Of Patient Representative |
Self |
eOther.15
-
Signature Status |
Signed |
eOther.16
-
Signature File Name |
release-EMS1.png |
eOther.17
-
Signature File Type |
image/png |
eOther.18
-
Signature Graphic |
|
eOther.19
-
Date/Time of Signature |
October 4, 2023, 10:39:20 GMT-06:00 |
eOther.20
-
Signature Last Name |
Tremblay |
eOther.21
-
Signature First Name |
Josue |