ASTM F2076-2001(2006) Standard Practice for Communicating an EMS Patient Report to Receiving Medical Facilities《EMS病人报告关于接收医疗设备的通知的标准实施规程》.pdf

1、Designation: F 2076 01 (Reapproved 2006)Standard Practice forCommunicating an EMS Patient Report to Receiving MedicalFacilities1This standard is issued under the fixed designation F 2076; the number immediately following the designation indicates the year oforiginal adoption or, in the case of revis

2、ion, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon (e) indicates an editorial change since the last revision or reapproval.INTRODUCTIONThroughout all areas of emergency medical services (EMS), there exists a need for the EMSprovider to

3、 consult with medical direction and receiving medical facilities. These consultations can bepurely for patient arrival notification, medical consultation, or to request additional medicalintervention orders. Within the EMS community, no “standard” reporting scheme exists. Hundreds ofverbal reporting

4、 formats are currently used. Some agencies divide these further for those assessmentsinvolving medical from trauma. Failure to use a standard reporting scheme makes initial studenteducation difficult, makes recording of information cumbersome, and can lead to time delays in patientcare or worse yet

5、an error.This consensus format was developed from a survey sent to over 100 emergency physicians, nurses,and field providers. The 25 that were returned were analyzed to construct the initial draft. One cleartheme was present. Receiving medical facilities want to know the most important informationfi

6、rst . . . medical information that affects the logistics of running a busy emergency department (ED).With the increased use of standing orders, the traditional detailed report to the ED was often not seenas time effective or making any change in the patients outcome.This practice uses the acronym PI

7、SA to describe the information to be presented in a generic patientreport. P is priority information that is considered absolutely critical if only 15 s of transmission (orreception) is accomplished; I is important information that needs to be communicated if an additional16 to 30 s is available; S

8、is significant information that would be transmitted if an additional 31 to 60s were available; A is additional information that should be transmitted if 61+ s are available.1. Scope1.1 This practice establishes the EMS standard for commu-nications entailing a patient radio (phone) report to a recei

9、vingmedical facility.1.1.1 This report is based on receiving facility needs and isgeneric for medical, traumatic, (ALS), and (BLS) patients.1.1.2 This report standard is based on the hierarchicalinformation needs of an average medical receiving facility.2. Referenced Documents2.1 ASTM Standards:2F 1

10、418 Guide for Training the Emergency Medical Techni-cian (Basic) in Roles and ResponsibilitiesF 1629 Guide for Establishing Operating Emergency Medi-cal Services and Management Information Systems, orBothF 1651 Guide for Training the Emergency Medical Techni-cian (Paramedic)2.2 Other Documents:USDOT

11、 National Standard Curriculum for EMT-B3USDOT National Standard Curriculum for EMT-P33. Terminology3.1 Definitions of Terms Specific to This Standard:3.1.1 AVPUa brief neurological examination to determinea baseline level of consciousness and to assess central nervoussystem function. This assessment

12、 is universally taught as partof the initial assessment for EMS providers.3.1.2 Alert3.1.3 responds to Verbal stimuli1This practice is under the jurisdiction of ASTM Committee F30 on EmergencyMedical Services and is the direct responsibility of Subcommittee F30.04 onCommunications.Current edition ap

13、proved March 1, 2006. Published March 2006. Originallyapproved in 2001. Last previous edition approved in 2001 as F 2076 01.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service at serviceastm.org. For Annual Book of ASTMStandards volume information, r

14、efer to the standards Document Summary page onthe ASTM website.3Available from U.S. Government Printing Office Superintendent of Documents,732 N. Capitol St., NW, Mail Stop: SDE, Washington, DC 20401.1Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959,

15、 United States.3.1.4 responds to Painful stimuli3.1.5 Unresponsiveno gag or cough3.1.6 Glasgow Coma Scale (GCS)standard neurologicalevaluation that uses eye opening, motor response, and verbalresponse. This assessment is universally taught as part of thedetailed assessment for EMS providers.3.1.7 LO

16、Clevel of consciousness.3.1.8 PMSneurological evaluation checking pulses, mo-tor, sensory status of the four extremities.3.1.9 trauma scorenumerical injury rating system basedon several parameters that may include patient body regioninjured, type of injury, central nervous system assessment, andvita

17、l sign evaluation.4. Significance and Use4.1 This practice establishes the national standard for train-ing the EMT in communicating pertinent patient information tothe receiving medical facility.4.2 Appropriate physiological data and patient assessmentinformation should be collected from the scene o

18、r while enroute to the receiving medical facility or medical commandsite.4.3 This practice is based on the information needs of areceiving medical facility to assist them in medical triage, EDresource management, and the provision of medical direction.4.4 This practice should be used by those who de

19、velopcurricula, provide continuing medical education, or desire aneeds-based reporting approach.4.5 This practice should be used to develop documentationaids such as EMS note pads and medical command documen-tation sheets.4.6 The communication format in each PISA subsection inthe practice are not ne

20、cessary in sequential order. The reportmay vary dependent upon patient presentation.5. Communication of Pertinent Patient Information5.1 After establishing communications with the receivingmedical facility, patient information will be reported in thefollowing format:5.1.1 Organization of patient med

21、ical information into thecategories of Priority, Important, Significant, Additional.5.1.1.1 Priority = “Need to know” or critical information tobe transmitted in the 0- to 15-s time frame.5.1.1.2 Important = Additional important informationtransmitted in the 16- to 30-s time frame.5.1.1.3 Significan

22、t = Additional information that supportsthe critical information; transmitted in the 31- to 60-s timeframe.5.1.1.4 Additional = “Nice to know” information transmit-ted in the 61+-s time frame.5.1.2 PPriority information items to be communicated:5.1.2.1 Units name or call sign,5.1.2.2 EMS provider id

23、entification,5.1.2.3 Patient age and gender,5.1.2.4 AVPU/LOC,5.1.2.5 Chief complaint, and5.1.2.6 Mechanism of injury/nature of illness.5.1.3 IImportant information items to be communicated:5.1.3.1 Respiratory status,5.1.3.2 Level of distress,5.1.3.3 Skin color and condition, and5.1.3.4 Vital signs.5

24、.1.4 SSignificant information items to be communi-cated:5.1.4.1 Scene description if pertinent,5.1.4.2 History of the present illness,5.1.4.3 Medications taken by patient,5.1.4.4 Pertinent technical findings,(1) Pulse oximetry,(2) Glucometer,(3) Three-lead/twelve-lead EKG, and(4) Other.5.1.4.5 Head/

25、neck assessment, and5.1.4.6 Glasgow Coma Scale/Trauma Score.5.1.5 AAdditional information items to be added if up to61+ s were available:5.1.5.1 Further neurological assessment (if needed),5.1.5.2 Abdominal assessment/pelvic stabilization,5.1.5.3 Extremity assessment (PMS),5.1.5.4 Allergies (if pert

26、inent),5.1.5.5 Field treatment provided,5.1.5.6 Response to field treatment,5.1.5.7 Destination, and5.1.5.8 Estimated time of arrival.6. Documentation Template6.1 Fig. 1 is a sample receiving medical facility form.7. Keywords7.1 emergency medical services; patient report formF 2076 01 (2006)2ASTM In

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29、hould be addressed to ASTM International Headquarters. Your comments will receive careful consideration at a meeting of theresponsible technical committee, which you may attend. If you feel that your comments have not received a fair hearing you shouldmake your views known to the ASTM Committee on S

30、tandards, at the address shown below.This standard is copyrighted by ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959,United States. Individual reprints (single or multiple copies) of this standard may be obtained by contacting ASTM at the aboveaddress or at 610-832-9585 (phone), 610-832-9555 (fax), or serviceastm.org (e-mail); or through the ASTM website(www.astm.org).FIG. 1 Sample Receiving Medical Facility FormF 2076 01 (2006)3