Medical Incident Report (Events)

TCB Event Medical Incident Report

To report an incident, please provide the following information
- Event Name
- Dispatch Reason*
- Date and Time when Incident Occurred:*
  
  MonthDayYearHourMinutes
- Incident Location
- Time Of Arrival
  
  :HourMinutes
- Time of Clear
  
  :HourMinutes
- TCB Staff 1*
  
  First NameLast NamePosistion
- TCB Staff 2
  
  First NameLast NamePosition
- Additional/Observer
  
  First NameLast NameERT Tech Number (If applicable)
- Full Name of Patient*
  
  First NameMiddle NameLast Name
- Date of Birth
  
  MonthDayYear
- GuestEmployeeVendorOther
- MaleFemaleN/A
- Phone Number
  
  Area CodePhone Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Chief Complaint*
- Patient Medical Details - S.A.M.P.L.E.*
- Vital Signs
  
  Heart RateBlood PressureRespiratory RateSPO2
- Care provided? (Assessment, vitals, apply oxygen, airway management, bleeding control...)*
- Care Provided By:
- ImpliedExpressed
- Parent / Guardian
  
  RelationshipFirst NameLast NamePhone
- Parent / Guardian Address If Different Than PT Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Narrative (Chronological or CHART)*
- By POVBy FireBy AmulanceBy Other Responsible AdultRefused TransportNo Transport Needed
- YESNO
- Date Of Refusal
  
  MonthDayYear
  DateHourMinutes
- Patient Signature For Above Refusal
- Notes/Additional Information
- Contact
  
  TypeFirst NameLast NamePhone
- Contact
  
  TypeFirst NameLast NamePhone
- FIRE / EMS
  
  First NameLast NameUnit #
- Other
  
  First NameLast NamePhone
- I certify that to the best of my knowledge the above information is true and correct.
- Signature
- Employee Submitted On
  
  MonthDayYear
  DateHourMinutes
- YESNONone Available
- TCB Supervisor On Duty
- Photos
  
  Browse Files
  
  Cancelof
- Should be Empty:

TCB Event Medical Incident Report