 MERS  Direct Line

AMBULANCE RUN REPORT KLINIK KESIHATAN MEMBAKUT

Time call received: am pm Date :
Time ambulance dispatched: am pm PATIENT INFORMATION
Time ambulance arrived at scene: am pm Patient name :
Time ambulance left scene: am pm Age : Gender : Male Female
Time arrived at hospital: am pm Race (if any) :
REASON IF DISPATCH MORE THEN 5 MINUTES I/D No. (if available) :
Type of ID :  My Card  Passport  Others
 Caller uncooperative  Location inability to obtain
 Language barier  High call volume Contact No. (if available) :
 No ambulance available  Safety condition Patient Address (if any) :
 Technical failure  Staff delayed
 Others, Please state :  No staff available

VITAL SIGNS
Time BP PR RESP SPO2 Temp Pain Score Taken By
am pm /10
am pm /10
am pm /10
am pm /10
PATIENT HISTORY
Chief Complaint :
Allergic :  No  Yes. Please state :
Medication :  No  Yes. Please state :
Past Medical History :  None  HPT  DM  Asthma  Cardiac  Stroke Last meal: am pm

 Epilepsy  Others. Please state :

EXAMINATION
Primary Survey
Response Airway Breathing Circulation

 Alert  Clear  Normal  Normal

 Voice  Noisy  Shallow  Pale
 Pain  Obstructed  Deep  Flushed
 Unresponsive  Absent  Cyanosed
Glascow Coma Scale
Eye Opening Verbal Motor

 Spontaneuosly (4)  Oriented (5)  Obey Command (6)

 To Speech (3)  Confused (4)  Moves to localized
 To Pain (2)  Inappropiate Word (3) pain (5)
 None (1)  Incomprehensible  Flexion withdrawal
Sound (2) from pain (4)
 None (1)  Abnormal flexion (3)
 Abnormal
extension (2)
 None (1)
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Other life threatening finding?
 None  Tension pneumothorax
 Open pneumothorax  Massive Haemothorax
 Flail Chest  Cardiac Tamponade

Signs of external bleeding?  Yes  No

IMMEDIATE CARE & TREATMENT
ABC Initial treatment Immobilization

 None  Chest compression  None  Spinal board

 Open airway
 Airway suctioned/
clearance
 Airway Inserted
 Rescue Breaths
 Cervical spine control
 Shock via AED
 Oxygen give via nasal
prong/high flow mask
 External bleeding control
 Arm sling  Extraction device
 Cervival collar  Log roll
 Upper limb Immobilize  Pelvic clamp
 Lower limb Immobilize  Others :
 Traction splint

Other treatment :  None  IV Drip (please state)  Nebulizer (please state)  Medication (please state)
 Bleeding control (please state)

DISPATCH CATEGORY DISTANCE DISPOSAL CREW INFORMATION

 Emergency run  0-5 km  First aid treatment and

MO :
 Transportation  6-10 km
 Dry run  11-15 km discharge home (via
 Disaster  More than 15 km medical direction) AMO :
 Bring back to unit
MEDICAL DISCIPLINE  Sent to other Nurse :
hospital/clinic.
 Medical  Trauma  Pediatric
Please state : Driver :
 Surgical  O&G
 Others
 Died/rigor mortis.
Others :
Handing over to police

TRIAGING :
Reported by :
RED 
YELLOW 
GREEN 
SARI 
WHITE 
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