LOG NUMBER TREATMENT FACILITY

ARRIVALDATE (Day, Month, Year) TIME

TRANSPORTATION TO FACILITY

MEDICAL RECORDEMERGENCY CARE AND TREATMENT

(Patient)

TIME ORDERS BY COMPLETED BY TIME PATIENT'S RESPONSE

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID no. (SSN or other); hospital or medical facility)

PATIENT'S HOME ADDRESS OR DUTY STATION

SEX

AGE

STREET ADDRESS

CITY STATE ZIP CODE

DUTY/LOCAL PHONEAREA CODE NUMBER

HOME PHONE

AREA CODE NUMBER

ITEM

INJURY OR OCCUPATIONAL ILLNESSWHEN (Date)

WHERE

HOW

VITAL SIGNSTIME

BP

PULSE

RESP

TEMP

WT

CATEGORY OF TREATMENT

EMERGENT

URGENT

NON-URGENT

TIME

INITIALS

EMERGENCY CARE AND TREATMENT (Patient) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10)

PULSE OX MONITOR ECGORDERS

CBC/DIFF ABG PT/PTT BHCG/URINE/BLOOD/QUANT

URINE C&S UA MSCC/CATH CHEM:

BLOOD C&S X

LAB

OR

DE

RS C-SPINE

ACUTE ABDOMEN

CXR PA & LAT/PORTABLE

LS SPINE

SINUS

X-R

AY

O

RD

ER

S

HEAD CT

ANKLE R/L

MILITARY STATUS

ITEMPRP

FLYING STATUSMEDICAL HISTORY OBTAINED FROM

YES NO N/A

THIRD PARTY INSURANCEITEM

ADDITIONAL INSURANCE

DD 2568 IN CHART

YES NO

NAME OF INSURANCE COMPANY

YES NO

IS THIS AN INJURY?

INJURY/SAFETY FORMS

EMERGENCY ROOM VISITDATE LAST VISIT 24 HOUR RETURN

TETANUSDATE LAST SHOT COMPLETED INITIAL SERIES

YES NO

YES NO

CHIEF COMPLAINT

DISPOSITIONHOME FULL DUTY

DISPOSITION QUARTERS /OFF DUTY24 HRS. 48 HRS. 78 HRS.

CONDITION UPON RELEASE

TIME OF RELEASE

ADMIT TO UNIT/SERVICE

IMPROVED

DETERIORATED

UNCHANGEDREFERRED

TO WHEN

I have received and understand these instructions.PATIENT'S SIGNATURE

CURRENT MEDICATIONS

ALLERGIES

PATIENT/DISCHARGE INSTRUCTIONS

MODIFIED DUTY UNTIL RETURN TO DUTY

RECORDS MAINTAINED AT

NSN 7540-01-075-3786

NSN 7540-01-075-3786

TEST RESULTS

PROVIDER HISTORY/PHYSICAL

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

WBC

H/H

GLUETOHBHCG

PCO2 SAT

ABG/PULSE OX

SUP 02 PH P02

OTHERPLT

DIP

MICRO

EKG INTERPRETATION

PATIENT'S IDENTIFICATION (For typed or written entries, give: Name -- last, first, middle; ID no. (SSN or other); hospital or medical facility)

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10)

CB

C

U/A

PT

APTT

SM

AC

RADIOLOGY Check if read by radiologist

RESULTS

DIAGNOSIS

CO

DE

S

CONSULT WITH TIME ACTION RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP

PROVIDER SIGNATURE AND STAMP