HICS 255 - MASTERPATIENTEVACUATIONTRACKING

PURPOSE:TheHICS255-MasterPatientEvacuationTrackingformrecordsthedispositionofpatients duringafacilityevacuation.

ORIGINATION:CompletedbyPlanningSectionSituationUnitLeaderordesignee(PatientTrackingManager).

COPIESTO:DistributedtothePlanningSectionChiefandtheDocumentationUnitLeader.

NOTES: TheformmaybecompletedwithinformationtakenfromeachHICS260-Patient EvacuationTrackingform. Ifadditionalpagesareneeded,useablankHICS255 andrepaginateasneeded.

NUMBER / TITLE / INSTRUCTIONS
1 / IncidentName / Enterthenameassignedtotheincident.
2 / OperationalPeriod / Enterthe startdate(m/d/y)andtime(24-hourclock)and enddateandtimefortheoperationalperiodtowhichthe formapplies.
3 / PatientEvacuationInformation
PatientName / Enterthefullnameofthepatient.
MedicalRecord# / Entermedicalrecordnumber.
EvacuationTriageCategory / Indicatethecategoriesasdefinedbythefacility(not necessarilythesameasemergencydepartmentadmitting triagesystem).
ModeofTransport / Indicatethemodeoftransportorwriteinifnotindicated.
Disposition / Indicatethepatient’sdisposition.
AcceptingHospitalorLocation / Entertheacceptinghospitalorlocation(e.g.,Alternate
CareSite,holdingsite).
Timehospitalcontacted
reportgiven / Entertimeprepared(24-hourclock).
TransferInitiated / Entertime,vehiclecompany,andidentificationnumber.
Medical RecordSent / Indicateyesorno.
MedicationSent / Indicateyesorno.
FamilyNotified / Indicateyesorno.
ArrivalConfirmed / Indicateyesorno.
AdmitLocation / Indicatetheapplicablesite.
Expired / Entertime(24-hourclock)ofdeceasedifnecessary.
4 / Preparedby / Enterthenameandsignatureofthepersonpreparingthe form.Enterdate(m/d/y),timeprepared(24-hourclock), andfacility.

HICS 255 - MASTERPATIENTEVACUATIONTRACKING

1.IncidentName / 2.OperationalPeriod (#)
DATE:FROM: TO: TIME:FROM: TO:
3.PatientEvacuationInformation
PATIENTNAME / MedicalRecord# / EvacuationTriageCategory
 IMMEDIATE  DELAYED  MINOR / ModeofTransport
 CCT  ALS  BLS  VAN
 BUSCAR  AIRCRAFT
Disposition
 DISCHARGE
 TRANSFER
 MORGUE / AcceptingHospitalorLocation / Timehospitalcontactedreportgiven
TransferInitiated(Time/TransportCo./#) / MedicalRecordSent
YES  NO / MedicationSent
 YES  NO / FamilyNotified
 YES  NO / ArrivalConfirmed
 YES  NO / AdmitLocation
 FLOOR  ICU
 ER MORGUE / Expired(time)
PATIENTNAME / MedicalRecord# / EvacuationTriageCategory
 IMMEDIATE  DELAYED  MINOR / ModeofTransport
 CCT  ALS  BLS  VAN
 BUSCAR  AIRCRAFT
Disposition
 DISCHARGE
 TRANSFER
 MORGUE / AcceptingHospitalorLocation / Timehospitalcontactedreportgiven
TransferInitiated(Time/TransportCo./#) / MedicalRecordSent
 YES  NO / MedicationSent
 YES  NO / FamilyNotified
 YES  NO / ArrivalConfirmed
 YES  NO / AdmitLocation
 FLOOR  ICU
 ER MORGUE / Expired(time)
PATIENTNAME / MedicalRecord# / EvacuationTriageCategory
 IMMEDIATE  DELAYED  MINOR / ModeofTransport
 CCT  ALS  BLS  VAN
 BUSCAR  AIRCRAFT
Disposition
 DISCHARGE
 TRANSFER
 MORGUE / AcceptingHospitalorLocation / Timehospitalcontactedreportgiven
TransferInitiated(Time/TransportCo./#) / MedicalRecordSent
 YES  NO / MedicationSent
 YES  NO / FamilyNotified
 YES  NO / ArrivalConfirmed
 YES  NO / AdmitLocation
 FLOOR  ICU
 ER MORGUE / Expired(time)
PATIENTNAME / MedicalRecord# / EvacuationTriageCategory
 IMMEDIATE  DELAYED  MINOR / ModeofTransport
 CCT  ALS  BLS  VAN
 BUSCAR  AIRCRAFT
Disposition
 DISCHARGE
 TRANSFER
 MORGUE / AcceptingHospitalorLocation / Timehospitalcontactedreportgiven
TransferInitiated(Time/TransportCo./#) / MedicalRecordSent
 YES  NO / MedicationSent
 YES  NO / FamilyNotified
 YES  NO / ArrivalConfirmed
 YES  NO / AdmitLocation
 FLOOR  ICU
 ER MORGUE / Expired(time)
4.PreparedbyPRINT NAME: SIGNATURE: DATE/TIME: FACILITY: