FLIGHT NWXEMS

MED [select name="REQ0" value="1|2|4|5|6|RESPONSE"] REQUESTED BY [checkbox name="REQ1" value="MEDICAL AIR TRANSPORT MISSION CONTROL|EAGLE MED|FLIGHT FOR LIFE|LIFESAVE|GRMC"] FOR [checkbox name="REQ2" value="TRANSPORT OF FLIGHT CREW FROM AIRCRAFT TO HOSPITAL|FLIGHT CREW PICK-UP PATIENT|RETURN TO AIRCRAFT W/ FLIGHT CREW AND THEIR PATIENT|TRANSPORT OF FLIGHT CREW AND THEIR PATIENT FROM HOSPITAL TO AIRCRAFT"] 

[checkbox name="EXT1" value="GROUND UNIT ARRIVED AT AIRPORT/AIRCRAFT AREA TO PICKUP FLIGHT CREW. DURING THIS TIME PERIOD, THE PATIENT LOADING DEVICE WAS SECURED TO GROUND UNIT STRETCHER BY FLIGHT CREW. GROUND CREW GATHERED FLIGHT CREW EQUIPMENT AND ASSISTED PERSONNEL W/ LOADING THEM IN GROUND UNIT. FLIGHT CREW THEN SECURED THEMSELVES IN THE PT COMPARTMENT AREA. GROUND EMS SERVICE PROVIDER, AS THE DRIVER, DEPARTS AIRCRAFT/AIRPORT AREA ENROUTE TO HOSPITAL FOR PATIENT PICKUP."]

[checkbox name="ext2" value="PRIOR TO GROUND UNIT ARRIVAL -"] AIR MEDICAL TRANSPORT CREW LOCATED PT ROOM AND THE NURSE IN CHARGE OF PATIENT. THEY OBTAINED DOCUMENTATION FOR TRANSPORT, VERIFIED DESTINATION, ESTABLISHED AT LOCATION PATIENT CURRENT DIAGNOSIS OF[text name="admitdx" size = 70 default=" "].

AIR MEDICAL TRANSFER FOR FOLLOWING REASON: [checkbox name="reason" value="SERVICES NOT AVAILABLE AT PRESENT FACILITY IN|HIGHER LEVEL OF CARE IN|CARDIOLOGY|NEUROLOGY|CARDIOLOGY|CARDIAC CATH LAB|ONCOLOGY|PEDIATRIC SPECIALTY|SURGERY|BEHAVIORAL MEDICINE|OBGYN|STROKE|TRAUMA|BURN UNIT|CRITICAL CARE|PULMUNOLOGY|NEPHROLOGY|IMAGING|GASTROENTEROLOGY"][text name="reason_text" size = 70 default=" "]

GROUND MEDICAL TRANSPORT NOT USED DUE TO: [checkbox name="reason_0" value="UNAVAILABLE UNIT|CRITICAL PATIENT REQUIRING CRITICAL CARE TRANSPORT|UNAVAILABLE ALS UNIT|UNAVAILABLE PARAMEDIC UNIT"][text name="reason_0_text" size = 70 default=" "]

GROUND UNIT CONSENT SIGNATURE FOR TRANSPORT ASSIST: [checkbox name="signature" value="OBTAINED FROM PATIENT|OBTAINED FROM GUARDIAN/POA|OBTAINED FROM RESPONSIBLE PARTY|NOT OBTAINED FROM PATIENT|UNABLE TO SIGN|LAW ENFORCEMENT SIGNED AS|NURSE SIGNED AS|EMS CREW SIGNED AS|REPRESENTATIVE|WITNESS|NO REPRESENTATIVE AVAILABLE"][text name="signature_text" size = 70 default=" "]

[checkbox name="ext3" value="DURING THIS BRIEF TIME PERIOD, THE PATIENT LOADING DEVICE WAS SECURED TO GROUND UNIT STRETCHER BY FLIGHT CREW."]

THROUGHOUT THE REMAINDER OF THIS CALL THE FLIGHT CREW ASSUMED AND MAINTAINED ALL PATIENT CARE TO INCLUDE BUT NOT LIMITED TO ALL ASSESSMENTS, TREATMENTS, AND MONITORING.

PATIENT REPORT PER ED DOCUMENTATION: [textarea name="report_text" default=" "]

PATIENT MOBILITY ON SCENE: [checkbox name="pe_mobil1_check" value="PATIENT ABLE TO AMBULATE TO PATIENT LOADING DEVICE SECURED ON STRETCHER|PATIENT MOVED TO PATIENT LOADING DEVICE SECURED ON STRETCHER VIA DRAW-SHEET METHOD|PATIENT PLACED ON PATIENT LOADING DEVICE SECURED ON STRETCHER USING SPINEBOARD|W/ INCIDENT|W/O ASSISTANCE|W/ ASSISTANCE|W/O INCIDENT OR PAIN EXPRESSION OR DISCOMFORT|W/ PAIN/DISCOMFORT EXPRESSED|SECURED PATIENT TO PATIENT LOADING DEVICE USING A 4-POINT HARNESS AND 3 STRAPS|SUPINE POSITION|LOW FOWLER'S POSITION|SEMI-FOWLER'S POSITION|FOWLER'S POSITION|FULL FOWLER'S/SITTING POSITION|LOADED INTO GROUND UNIT FOR TRANSPORT W/O INCIDENT"][text name="pe_mobil1_text" size = 70 default=" "]

DURING TRANSPORT TO AIRCRAFT/AIRPORT, FLIGHT CREW WAS BEDSIDE WITH PATIENT IN MODULE OF GROUND UNIT. GROUND SERVICES PROVIDERS DID NOT ACCOMPANY FLIGHT CREW DURING THIS TIME. GROUND SERVICES PROVIDERS SUCH AS MYSELF AND/OR PARTNER WERE SEATED IN THE FRONT CAB AS DRIVER & PASSENGER.  

UPON ARRIVING AT DESTINATION, THE GROUND UNIT WAS PARKED IN THE PROPER CLEARANCE AREA FOR UNLOADING/LOADING PATIENT TO AND FROM AIRCRAFT. I, EXITED THE DRIVER SEAT AND OPENED THE REAR GROUND UNIT DOORS. FLIGHT CREW HAD PREPARED PATIENT UPON THE PATIENT LOADING DEVICE ON STRETCHER FOR AIRCRAFT LOADING. GROUND CREW THEN REMOVED THE STRETCHER, DEVICE AND PATIENT FROM THE GROUND UNIT AND PLACED IT NEAR AIRCRAFT. FLIGHT CREW ASSEMBLED SKID LOADING STRUCTURE ON AIRCRAFT AND THEN "ZONED IN" THE STRETCHER TO LOAD THE PT. USING THE PATIENT LOADING DEVICE ON THE STRETCHER THE FLIGHT CREW PUSHED THE APPARATUS UP AND INTO THE AIRCRAFT[text name="incident_text" size = 30 default=" "]. 

LEAD PERSON RECEIVING PATIENT:[text name="pers_text" size = 55 default=" "],[checkbox name="pers_check" value="RN|LVN|CCRN|FP-C|APRN|FNP|ARNP|APA|PA|MD|RRT"]

REPORT WRITER:[text name="WRITER" size = 55 default=" "] EOR