PATIENT ENCOUNTER FORM

Event: -1.lttl:'..l~b~Gf:.____ __ ___

DATE & TIME (24hR) CLINICAL IMPRESSION OF CARE PROVIDER
last Name vs2·.,-ca--J:-(l---G-~-o-l-.----- Abraslondental hypotermla
First Name :-~.... ....,_- ---.!~ --~~~ L_ _ _ _ __ D D~catlo n D Intoxication
D Blister
Phone D Chest Pain lk31>izzlness D Laceration
Go D Concussion □ Fracture D Sprain/Strain
Age ,!th (\. D Female [SJ-Male
DOB D Contusion D Hyperthermia
Family Physician : Other ~I ~u,-
--- --- --- --- ---
MEDICATION or IV GIVEN
PATIENT CAT EGO RY_ ____ ____ ____ _ Provider Name :
A=Athlete E-Event Staff, P=Perfonner, S=Spectator, U=Unknown Time: Medication/IV
• -
r~-00 :a.w
PARTICIPANT ID
--- --- --- --- --- --
(Race/Bib Number)
TRIANGLE ACUITY SCALE*"'
0 Black □ Red O Yellow O Red ~n □White
TREATMENT & SERVICES PROVIDED

PRESENTING COMPLAINT $'FJ tt k \c,e re Ig. -t-'j e.-, D Antacid D Splint/Taping/Tensor

D Stretching
~~n.c,~ le., t.Jwo-\ ~ D Counselling
□ Tylenol
HISTORY D Ibuprofen
·'\r~-,-le_,,\,....~.....h-9'1\--,.,....t-~.,.,P-1vi-,-,-.'1·q-V')_ _ __ D Immobilization D Vaseline
D R.1.C.E. D Wound Management
D Sling D Other_ _ _ _ __
D Other .Alrlloth~ID lO~ Other_ _ _ __
Past History_ _ _ _-'-":,___ _ _ _ _ _ _ _ _ _ __ lll~\?) .
DISCHARGE ACUITY SCALE** /

Medications_ _ _ _'=",,_____ ___ ___ ___ D Black D Red □Yellow

D Red ~Gree n ~hi~

FOLLOW-UP DISPOSITION
Allergies_ _ _ _ _....,e:,..,L.._ _ _ _ _ _ _ _ _ _ _ __
~ent Medical Team ~eturn ed to Event/work
□ ER D Left Event (Private Vehicle)
VITAL SIGNS D Family Physician/Clinic D Left Event (taxi)
Level Of Consciousness
#1 #2 #3 □ other_ _ _ _ __ D Left Event (event staff)
(AVPU)
Time __m _ 0 Ambulance Transport
L A L a.{:, o,, D Air Evacuation
.R Temp.
~-- □ AMA
~
Pulse
D Other_ _ _ _ _ __
B.P. ~~\~ /9s2
R.R. _w_
Sa02
Glucose
--» ¾ DISCHARGE INSTRUCTIONS._ _,1-.e!i+'•._.)'.:_~_~__:_:=--:...._ _ __

GCS ts:: ADDITIONAL NOTES._ _ _ _ _ _ _ _ _ _ _ __

PHYSICAL FINDINGS

Di~ ~he ~are pro~ided ~~ site prevent a visit to ~ther medic

JZI
facility (1.e. hospital, clime, family doctor)? Yes ~

MGMPt. ID:
"DOB, PHN, Family Physician (Optional)
..Triage/Discharge Acuity Scale Level
LEVEL OF TRAININF OF CARE PROVIDER**
--= ---- --
Black/Deceased-obvious non-survivablle injury LOCATION CARE WAS PROVIDED.-:-_C,tl..:..:..;;_..:~:..i..1_ _ _ __
Red/emergent-Critical, resucitatlon, Chest Pain, Collapse
Yellow/uraent-Ow!rdose no ABC compromise. SOB
Green/Minor-Assessment required, wound care, prescriptions
DISCHARGETIME._ __ f:. ., c. .·_,.:.. .v_- -:~- ----
Name of Attendant (Please PRl;1:-----'~=-jb:}£:1--=.-__ __
White/Dispensary- Product ~uesn, CostumerCervise RAID :

••Lewi of Tnlnlng of care Pro11lder

PCP, SFA, OFA. EMR, LPN, RN, NP, MD, Chlro, Physlo, etc Signature of Attendan~:a--==~:f::!~
1
=-- ---- ----