The Values used to describe Null fields Not Available Not Known Not Reporting Not Recorded Not Applicable The date/time the EMS provider requested ALS or Air response (IT5.10) or the ALS or Air arrived (IT5.11). Respiratory Regularity Regularly-Regular Regularly-Irregular Irregularly-Irregular The Agency ID of the service that care is being received from The unique Call Number of the service that care is being received from The Agency ID of the service that care is being transferred to The unique Call Number of the service that care is being transferred to Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire Initial Trip Return Trip Transfer Trip Round Trip Medicare Questionaire Closest Facility Request of Physician Request of Family Specialized Care To Rehabilitation Center Medicare Questionaire Medicare Questionaire Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire Working Aged Benif/Spouse With Employer Plan ESRD Benif In 12 Month Coord Period With Employer Plan No Fault Insurance Including Auto/Other Workers Comp PHS or Other Federal Agency Black Lung VA Disabled Beneficiary Under Age 65 wtih LGHP Any Liability Insurance Medicare Questionaire Jr Sr I II III IV Medicare Questionaire Medications Wallet/Purse Insurance Card Clothing Glasses ID Card/License False Teetch Jewelry Other None Keys Cell Phone Medicare Questionaire Medicare Questionaire At Incident Location wtih Family/Friends At Incident with Law Enforcement At Destination with Staff (Includes Aeromed staff) At Destination with Patient At Other Medicare Questionaire Medicare Questionaire AGAINST MEDICAL ADVICE, refuse medical care, transportation, and/or advice by this agency. REQUEST RELEASE, as I do not feel my condition requires emergency care and/or transportation by this agency. REFUSE SPECIFIC care, advice, or recommended destination as provided by this agency. Medicare Questionaire Medicare Questionaire Chief Complaint Resolved Feels ambulance transport not necessary Private tx to hospital/PMD available Other Medicare Questionaire Stay home and monitor Go home and monitor Private auto to hospital Private auto to PMD Call PMD Other Medicare Questionaire Family Friends Legal Guardian/DDM Law Enforcement Responsible Adult (i.e. School Nurse) Other Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire The patient's alternate home mailing or street address The patient's alternate home city or township or residence The FIPS code for the patient's alternate home city or township or residence The patient's alternate home state, territory, or province, or District of Columbia, where the patient resides The FIPS Code for patient's alternate home state, territory, or province, or District of Columbia, where the patient resides patient alternate county or parish or residence patient alternate county or parish or residence The FIPS code for the patient alternate county or parish or residence patient alternate country of citizenship The FIPS code for the patient alternate country of citizenship The patients alternate home or primary telephone number Medicare Questionaire Requires Oxygen Requires Airway Monitoring/Suction Has Decubitus Ulcers and Requires Wound Precautions Signs of decreased LOC/Unconscious and Requires Monitoring Immobilized due to a fracture or possible fracture Ventilator Dependent Requires cardiac or other physiological monitoring Seizure prone and requires monitoring Weight limit exceeds wheelchair or stretcher van safety limits Requires restraints (other than seat belts) Requires IV maintenance Requires isolations precautions Can sit in a wheelchair, but is medically unstable due to other cconditions listed above Cannot support themselves safetly while seated in a wheelchair Requires medical supervision during transport Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire No Yes Medicare Questionaire SNF Bed NH Bed DRG Patient Hospice Patient Medicare Questionaire Patient's Legal Guardian Patient's Health Care Power of Attorney Person recv'g govt. benefits for patient Person arranging treatment or handles pt. affairs Representative of agency/institute furnishing care, services, assistance to pt. Name of facility that the EMS crew intended to respond to but were diverted from. Notification by EMS personnel to Emergency Department personnel of the Specialty Team requested. No Trauma STEMI Stroke / CVA (Priority 1, 2 or 3) assigned to a patient that is a scoring summarizing the patient status. The scoring considers the patient condition, physiological and anatomical injuries and mechanism of injury. Amp[utation proximal to wrist or ankle Blunt Trauma (no hemodynamic trauma) BSA less than 10% BSA greater than or equal to 10% Flail Chest GCS less than or equal to 13 GCS improving Hemodynamic compromise from trauma Minor injuries Open or depressed skull fracture Other single system injury Parlysis resultling from trauma Penetrating injuries to extremities Penetrating injury to trunk, neck, or head PTS less than or equal to 8 Respiratory compromise resulting from trauma Two or more proximal long bone fractures Unstable Pelvis Tender and/or Distended Abdomen Crushed, Degloved, or Mangled Extremity Single System Injury-Neurological Single System Injury-Orthopedic Single System Injury-Maxillofacial Ejection of Patient from Enclosed Vehicle Auto/Pedestrian, Auto/Bike or Motorcycle Crash with Significant Impact Falls Greater Than 20 Ft or Distance 2-3 Times Height of Patient Significant Assault or Altercations High Risk Auto Crash Notification of Trauma Referral Center by EMS personnel, of the priority of the transported/transferred patient (to determine the appropriate destination facility for the unassigned patient, and to collect data on all patients. No Yes The number assigned to the patient by the Trauma Referral Center. One part of a complete assessment for a patient with chest pain/discomfort or suspected of having an acute cardiac event is obtained by using a 12 Lead ECG. No Yes The second part of a complete assessment for a patient with chest pain/discomfort or suspected of having an acute cardiac. No Yes The person(s) interpreting the 12 Lead ECG sent from the scene of the incident. EMT-Paramedic Computer Program Physician Segment Elevation Myocardial Infarction No Yes Inconclusive Pulse Oximetry Qualifier At Room Air High Concentration O2 (10-25 LPM) Low Concentration O2 (1-6 LPM) Medium Concentration O2 (7-9 LPM) Pre Ambulance AED Emergency Response Unit with AED First Responder with AED No pre-ambulance AED Public Access Defibrillation Unknown Pulse With PreAmbulance Defib Device not applied (or not working) No No Device Available Shock Not Indicated Yes Yes,But Re-Arrest Prior to Ambulance Airway Patent Compromised Obstructed Other EKG Ectopy No Ectopy Noted 12 Lead ECG-Anterior Ischemia 12 Lead ECG-Inferior Ischemia 12 Lead ECG-Lateral Ischemia Artifact AV Block-1st Degree Left Bundle Branch Block PAC - Premature Atrial Contractions PJC - Premature Junctional Contractions PVC - Premature Ventricular Contractions Right Bundle Branch Block S-T Segment Depression S-T Segment Elevation BBB EKG Cause For Change Initial Rhythm Spontaneous Medication Defibrillation Cardioversion Other Location taken for Blood Pressure Right Arm Left Arm Right Leg Left Leg Position of the Patient when vitals taken Fowlers Semi-Fowlers Sitting Supine Shock Standing TrendeIenburg Prone Right Lateral Recumbent Left Lateral Recumbent