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    Patient Encounter Form

    Uploaded by

    Spectator Medic
    This patient encounter form documents a medical event involving a patient. It records information such as the date and time, patient details like name and age, presenting complaint, physical assessment findings, vital signs, treatment provided, and discharge details. The form is used to document the medical care provided to the patient during the event.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Patient Encounter Form

    Uploaded by

    Spectator Medic
    357 views2 pages
    This patient encounter form documents a medical event involving a patient. It records information such as the date and time, patient details like name and age, presenting complaint, physical assessment findings, vital signs, treatment provided, and discharge details. The form is used to document the medical care provided to the patient during the event.

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    Patient Encounter Form

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    This patient encounter form documents a medical event involving a patient. It records information such as the date and time, patient details like name and age, presenting complaint, physical assessment findings, vital signs, treatment provided, and discharge details. The form is used to document the medical care provided to the patient during the event.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    357 views2 pages

    Patient Encounter Form

    Uploaded by

    Spectator Medic
    This patient encounter form documents a medical event involving a patient. It records information such as the date and time, patient details like name and age, presenting complaint, physical assessment findings, vital signs, treatment provided, and discharge details. The form is used to document the medical care provided to the patient during the event.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    PATIENT ENCOUNTER FORM

    Event : _______________________________________

    DATE & TIME (24hR)_______________________________________ CLINICAL IMPRESSION OF CARE PROVIDER


    Last Name :______________________________________________ Abrasiondental hypotermia
    First Name :______________________________________________ Blister Dislocation Intoxication
    Phone :______________________________________________ Chest Pain Dizziness Laceration
    Age :________________ Female Male Concussion Fracture Sprain/Strain
    DOB :________________ Contusion Hyperthermia
    Family Physician :__________________________________________ Other_______________________________________________

    PATIENT CATEGORY________________________________________ MEDICATION or IV GIVEN


    A=Athlete, E=Event Staff, P=Performer, S=Spectator, U=Unknown Time : Medication/IV Provider Name :
    PARTICIPANT ID___________________________________________
    (Race/Bib Number)
    TRIANGLE ACUITY SCALE**
    Black Red Yellow Red Green White
    TREATMENT & SERVICES PROVIDED
    PRESENTING COMPLAINT____________________________________ Antacid Splint/Taping/Tensor
    Counselling Stretching
    HISTORY_________________________________________________ Ibuprofen Tylenol
    ________________________________________________________ Immobilization Vaseline
    ________________________________________________________ R.I.C.E. Wound Management
    ________________________________________________________ Sling Other________________
    Other_______________ Other________________
    Past History_______________________________________________
    _________________________________________________________ DISCHARGE ACUITY SCALE**
    Medications_______________________________________________ Black Red Yellow Red Green White
    _________________________________________________________
    Allergies__________________________________________________ FOLLOW-UP DISPOSITION
    _________________________________________________________ Event Medical Team Returned to Event/work
    ER Left Event (Private Vehicle)
    Level Of Consciousness VITAL SIGNS Family Physician/Clinic Left Event (taxi)
    (AVPU) #1 #2 #3 Other_______________ Left Event (event staff)
    Time ______ ______ ______ Ambulance Transport
    Temp. ______ ______ ______ Air Evacuation
    Pulse ______ ______ ______ AMA
    B.P. ______ ______ ______ Other_________________
    R.R. ______ ______ ______
    SaO2 ______ ______ ______ DISCHARGE INSTRUCTIONS_____________________________
    Glucose ______ ______ ______ _____________________________________________________
    GCS ______ ______ ______ ADDITIONAL NOTES____________________________________
    PHYSICAL FINDINGS _____________________________________________________
    __________________________________________________________ _____________________________________________________
    __________________________________________________________ _____________________________________________________
    __________________________________________________________ Did the care provided on site prevent a visit to another medic
    __________________________________________________________ facility (i.e. hospital, clinic, family doctor) ? Yes No

    *DOB, PHN, Family Physician (Optional) MGM Pt. ID:


    **Triage/Discharge Acuity Scale Level
    LEVEL OF TRAININF OF CARE PROVIDER**___________________
    Black/Deceased-obvious non-survivablle injury
    Red/emergent-Critical, resucitation, Chest Pain, Collapse ______________
    LOCATION CARE WAS PROVIDED___________________________
    Yellow/Urgent-Overdose no ABC compromise, SOB
    Green/Minor-Assessment required, wound care, prescriptions
    DISCHARGE TIME________________________________________
    White/Dispensary- Product Requests, Costumer Cervise RA ID :
    Name of Attendant (Please PRINT)_________________________
    **Level of Training of Care Provider
    PCP, SFA, OFA, EMR, LPN, RN, NP, MD, Chiro, Physio, etc ______________
    Signature of Attendant___________________________________

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