EMS Follow Up V2

1
Your Name* This field is required.
First Name
Last Name
2
Your OEMS Certification Number* This field is required.Please include the letter at the start of your certification number
Example: E123456789
3
Your Email* This field is required.This should be an email address that you regularly check. No HIPAA information will be sent to your email address.
example@example.com
4
Your Phone Number* This field is required.This should be a phone number that a representative of the facility can use to contact you and provide an update.
5
Phone Number for Monday
6
Choose your agency.* This field is required.Begin typing in your agencies name and the field will autofill.
If your agency is not listed contact ODEMSA
7
Agency for Monday
8
What date did you run the call?* This field is required.Note that the date should be the date of the call when it was documented on your PPCR.
Date
Month
Day
Year
9
Enter Your Unit Number* This field is required.Please enter your unit number (You will be asked to provide another unit number if care was transferred)
10
Enter Your EMS Incident Number* This field is required.Please input the entire incident number as it appears on your patient documentation.
11
My patient was:* This field is required.This helps hospital staff locate your patient medical records.
transported by my agency
turned over to another ground ambulance
turned over to air medical transport (helicopter)
12
What ground transport agency was your patient turned over to?* This field is required.Begin typing in your agencies name and the field will autofill.
13
Ground Transport Agency for Monday
14
What was the unit number your patient was turned over to?This is not required but may help to track down your patient.
Example: Medic 14, Fire Medic 14, Ambulance 14, Rescue 14, etc.
15
What air medical transport agency was your patient turned over to?* This field is required.
*Air Care Eagle
*VCU LifeEvac 1
*VCU LifeEvac 3
*VCU LifeEvac 4
*Virginia State Police-Med Flight
Aeromedical Transport Specialists
Centra One
LifeEvac Virginia
Life Guard/Carilion Patient Transport Specialists
Fairfax County Police
Nightingale Regional Air Ambulance Service
Pegasus Flight Operations
PHI Air Medical/AirCare
Wings Air Rescue
zz-Unknown
16
What time was your patient turned over to the other agency?* This field is required.This doesn't have to be an exact time but your estimated time may help to track down your patient.
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
PM
AM
PM
17
What facility was your patient transported to?* This field is required.If a facility is not listed, it is not currently part of this initiative. You should contact the hospital liaison directly.
Bon Secours Ashland Emergency Center
Bon Secours Chester Freestanding Emergency Center
Bon Secours Colonial Heights Emergency Care
Bon Secours Memorial Regional Medical Center
Bon Secours Richmond Community Hospital
Bon Secours Short Pump Emergency Center
Bon Secours Southern Virginia Medical Center
Bon Secours Southside Medical Center
Bon Secours St. Francis Medical Center
Bon Secours St. Mary's Hospital
Bon Secours Westchester Emergency Center
Children's Hospital of Richmond at VCU Children's Tower
HCA Chesterfield ER
HCA Chippenham Hospital
HCA Hanover Emergency Center
HCA Henrico Doctors' Hospital
HCA Johnston Willis Hospital
HCA Parham Doctors' Hospital
HCA Prince George ER
HCA Retreat Hospital
HCA Scott's Walk ER
HCA Swift Creek Emergency Room
HCA TriCities Hospital
VCU Health Community Memorial Hospital
VCU Health Emergency Center at New Kent
VCU Health Systems
VCU Health Tappahannock Hospital
18
To direct your request appropriately, please select the most applicable choice below:* This field is required.
Medical Patient
Trauma Patient
STEMI Alert Patient
Stroke Alert Patient
Burn Patient
19
xTo direct your request appropriately, please select all that apply. My patient was a:
Medical Patient
Trauma Patient
STEMI Alert Patient
Burn Patient
Stroke Alert Patient
20
Let the receiving facility know if you have any questions, comments, or concerns related to this call. DO NOT provide any patient identifiers (HIPAA).Patient Identifiers include but are not limited to: Name, Date of birth, Phone number(s), Social security number, Address, etc.
DO NOT PUT IN A SOCIAL OR ANY OTHER HIPAA INFO
21
Date Submitted for Monday
Date
Month
Day
Year
Should be Empty: