ASTM F2076-2001(2014) 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: F2076 01 (Reapproved 2014)Standard Practice forCommunicating an EMS Patient Report to Receiving MedicalFacilities1This standard is issued under the fixed designation F2076; the number immediately following the designation indicates the year oforiginal adoption or, in the case of revisio

2、n, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon () 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 co

3、nsult 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 fo

4、rmats 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 an

5、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 informationfirst

6、 . . . 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 PISA

7、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 is

8、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 receivin

9、gmedical 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:2F1418

10、Guide for Training the Emergency Medical Techni-cian (Basic) in Roles and Responsibilities (Withdrawn2007)3F1629 Guide for Establishing Operating Emergency Medi-cal Services and Management Information Systems, orBothF1651 Guide for Training the Emergency Medical Techni-cian (Paramedic)2.2 Other Docu

11、ments:USDOT National Standard Curriculum for EMT-B4USDOT National Standard Curriculum for EMT-P43. Terminology3.1 Definitions of Terms Specific to This Standard:1This practice is under the jurisdiction of ASTM Committee F30 on EmergencyMedical Services and is the direct responsibility of Subcommitte

12、e F30.04 onCommunications.Current edition approved June 1, 2014. Published June 2014. Originallyapproved in 2001. Last previous edition approved in 2006 as F2076 01 (2006).DOI: 10.1520/F2076-01R14.2For referenced ASTM standards, visit the ASTM website, www.astm.org, orcontact ASTM Customer Service a

13、t serviceastm.org. For Annual Book of ASTMStandards volume information, refer to the standards Document Summary page onthe ASTM website.3The last approved version of this historical standard is referenced onwww.astm.org.4Available from U.S. Government Printing Office Superintendent of Documents,732

14、N. Capitol St., NW, Mail Stop: SDE, Washington, DC 20401, http:/www.access.gpo.gov.Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959. United States13.1.1 AVPUa brief neurological examination to determinea baseline level of consciousness and to assess

15、central nervoussystem function. This assessment is universally taught as partof the initial assessment for EMS providers.3.1.2 Alert3.1.3 responds to Verbal stimuli3.1.4 responds to Painful stimuli3.1.5 Unresponsiveno gag or cough3.1.6 Glasgow Coma Scale (GCS)standard neurologicalevaluation that use

16、s eye opening, motor response, and verbalresponse. This assessment is universally taught as part of thedetailed assessment for EMS providers.3.1.7 LOClevel of consciousness.3.1.8 PMSneurological evaluation checking pulses,motor, sensory status of the four extremities.3.1.9 trauma scorenumerical inju

17、ry rating system basedon several parameters that may include patient body regioninjured, type of injury, central nervous system assessment, andvital sign evaluation.4. Significance and Use4.1 This practice establishes the national standard for train-ing the EMT in communicating pertinent patient inf

18、ormation tothe receiving medical facility.4.2 Appropriate physiological data and patient assessmentinformation should be collected from the scene or while enroute to the receiving medical facility or medical commandsite.4.3 This practice is based on the information needs of areceiving medical facili

19、ty to assist them in medical triage, EDresource management, and the provision of medical direction.4.4 This practice should be used by those who developcurricula, provide continuing medical education, or desire aneeds-based reporting approach.4.5 This practice should be used to develop documentation

20、aids such as EMS note pads and medical command documen-tation sheets.4.6 The communication format in each PISA subsection inthe practice are not necessary in sequential order. The reportmay vary dependent upon patient presentation.5. Communication of Pertinent Patient Information5.1 After establishi

21、ng communications with the receivingmedical facility, patient information will be reported in thefollowing format:5.1.1 Organization of patient medical information into thecategories of Priority, Important, Significant, Additional.5.1.1.1 Priority = “Need to know” or critical information tobe transm

22、itted 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 Significant = Additional information that supportsthe critical information; transmitted in the 31- to 60-s timeframe.5.1.1.4 Additional = “Nice to know” informatio

23、n transmit-ted in the 61+-s time frame.5.1.2 PPriorityinformation items to be communicated:5.1.2.1 Units name or call sign,5.1.2.2 EMS provider identification,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 IImportantinf

24、ormation 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.5.1.4 SSignificantinformation 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 ta

25、ken 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/neck assessment, and5.1.4.6 Glasgow Coma Scale/Trauma Score.5.1.5 AAdditionalinformation items to be added if up to61+ s were available:5.1.5.1 Further neur

26、ological assessment (if needed),5.1.5.2 Abdominal assessment/pelvic stabilization,5.1.5.3 Extremity assessment (PMS),5.1.5.4 Allergies (if pertinent),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 Templa

27、te6.1 Fig. 1 is a sample receiving medical facility form.7. Keywords7.1 emergency medical services; patient report formF2076 01 (2014)2ASTM International takes no position respecting the validity of any patent rights asserted in connection with any item mentionedin this standard. Users of this stand

28、ard are expressly advised that determination of the validity of any such patent rights, and the riskof infringement of such rights, are entirely their own responsibility.This standard is subject to revision at any time by the responsible technical committee and must be reviewed every five years andi

29、f not revised, either reapproved or withdrawn. Your comments are invited either for revision of this standard or for additional standardsand should be addressed to ASTM International Headquarters. Your comments will receive careful consideration at a meeting of theresponsible technical committee, wh

30、ich 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 Standards, at the address shown below.This standard is copyrighted by ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959,

31、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). Permission rights to photocopy the standard may also be secured from the ASTM website (www.astm.org/COPYRIGHT/).FIG. 1 Sample Receiving Medical Facility FormF2076 01 (2014)3