EMS Follow Up V2

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IF THIS FOLLOW-UP IS RELATED TO A POSSIBLE COVID-19 EXPOSURE,

PLEASE CONTACT YOUR AGENCY-DESIGNATED INFECTIOUS DISEASE OFFICER

AND DO NOT USE THIS FORM
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Your Name* This field is required.
First Name
Last Name
3
Your State Certification Number* This field is required.
Example: E123456789
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Your Email* This field is required.
example@example.com
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Your Phone Number* This field is required.
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Choose your agency.* This field is required.Begin typing in your agencies name and the field will autofill.
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What date did you run the call?* This field is required.
Date
Month
Day
Year
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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)
9
Enter Your EMS Incident Number* This field is required.Please input the entire incident number as it appears on your patient documentation.
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Do you have your patient's Medical Record Number (MRN)? ***This field is NOT REQUIRED, but if you have it, your response turnaround should be significantly decreased***This is NOT a required field and may be left blank. However, it helps hospital staff find the patient in their system. IF you do not have an MRN, the response may be slower than if you had an MRN. This identifier help to locate the patient's chart while remaining HIPPA compliant and allows staff to pull the information sooner. If you do not have the MRN the person at the destination facility must wait for the EMS PCR to become a part of the patient hospital chart and your incident number to become part of the hospital's electronic health records system. Once compiled it may be searched to provide your update on your patient.
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My patient was:* This field is required.This helps hospital staff locate your patient.
transported by my agency
turned over to another ground ambulance
turned over to air medical transport (helicopter)
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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.
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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.
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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
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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
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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 - Chester 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 VA Medical Center
Bon Secours - Southside Medical Center
Bon Secours - St. Francis Medical Center
Bon Secours - St. Mary's Hospital
Bon Secours - Westchester Center
HCA - Chippenham Medical Center
HCA - Hanover Emergency Department
HCA - Henrico Doctor's Hospital (Forest)
HCA - Johnston Willis Hospital
HCA - Parham Doctor's Hospital
HCA - Prince George ER (FKA TriCities ER)
HCA - Retreat Doctor's Hospital
HCA - Swift Creek Emergency Center
HCA - TriCities Hospital (FKA John Randolph)
HCA - West Creek ER
VCU Health - Community Memorial Hospital
VCU Health - Emergency Center at New Kent
VCU Health - Tappahannock Hospital
VCU Health - VCU Medical Center
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