HCC: 518.324.4HCC
Tracking:518.324.TRAK / / Empire County Hospital
Patient Evacuation Critical Information and Tracking Form
Receiving Facility
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______
______
______
______
______/ Movement Times
At Holding: ______
At Loading ______
Left Facility______
ArrivedDest.______/ Place patientidentity label or imprint here or write in patient information
Name:Last ______First ______
MR #:______
Age:______Gender: M F DOB: ____/____/____
Admission Date:____/____/____ Unit: ______
Attending Physician:______Room or Bed #____
Patient Mobility Level
Transportation Assistance Level / Minimum Staff to Loading Area / Transport Agency: ______Unit/Vehicle # ______Transport Vehicle / Equipment / Items to Accompany Patient
Behavioral Health (blue) / Clinical / Non-Clinical
TAL 3 Ambulatory / 0 / 1:5 / Transit/School Bus / Oxygen
TAL2 Wheelchair / 0 / 1 / Wheelchair Van / Ambulette
Other (specify) ______ / Suction
TAL 1 Non-Ambulatory / Infusion Pump
1 / 1 / BLS Ambulance / Ventilator
TAL 1Moderate Acuity / 1 / 1 / Medications
TAL 1Critical Care / 1 / 2 / ALS Ambulance
Air Ambulance / MedEvac
Isolette/Neonatal Ambulance / Critical Supplies
TAL 1Interrupted Procedure
(specify)______/ 2 / 2 / Medical Record
ThisGO Pouch
TAL 1 Arm Carry / 0 / 1 / Patient Accompanied by Guardian / Other ______
Isolation Status / Contact / Droplet / Airborne / Other ______
Primary (Significant) Diagnosis: ______/ Relevant Co-morbidities: Cardiac Diabetes
Hypertension Other ______
Advance Directives / Name/Contact #______/ Interpreter Needed? ASL Language: ______
DNR / DNI / Healthcare Proxy / Living Will / MOLST / CopyEnclosed
Allergies / None Latex Other: ______
Mental Status / Oriented / Alert / Lethargic / Mildly Confused / Severely Confused
Behavior Problems/Safety Risk / None / Wanders / Elopement Risk / Verbally Abusive / Physically Abusive
Fall Risk / None / Low / High
Restraint / Vest/Posey Wrist/Mitt 4-Point Other ______/ Date / Time Applied: ______
Special Requirements / Oxygen (mask)lpm____ / Oxygen (cannulae)lpm____ / Suction / Seizure Precautions
IV Access / Saline Lock / Continuous / PICC Line / Central Line
Other Intravascular Device ______/ Solution / Rate ______/ Tube Feeding
Transfers / Independent / Supervision / Partial Assist 1 / Partial Assist 2 / Total Assist
Activities of Daily Living
Independent / Supervision / Partial Assist / Total Assist
Continent / Incontinent Bowel / Incontinent Bladder / Other ______
Diet / Special: ______/ Consistency / Aspiration Precautions
NPO / Regular: / Regular / Ground / Pureed / Thickened / Liquid
Personal Assistive Devices with the Patient
None / Cane / Walker / Personal Wheelchair / Glasses
Dentures / Hearing Aid / Prosthesis Type: ______/ Other ______
Notifications(name/date/time) / Family: / Private MD:
Last Actions Prior to Departure Document time and findings
Last Temperature______ / Last Heart Rate
______ / Last Blood Pressure______ / Last Accu-Check______ / Last Breath Sounds ______
Last Medications Given (name/dose/route/time): ______ / Last Meal (food/date/time): ______
Next Medications / Intervention Needed None until: ______
Name / Day/Time Needed / Administered? / By / Date / Time
Yes No
Yes No
Yes No
Notes During Transit Document all care given or status updates. Use other side if needed.
Time / Note