医疗记录补充医疗数据MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA

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For use of this form,see AR 40-66;the proponent agency is the Office of the Surgeon General

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REPORT TITLE

**Tactical** **Evacuation** **After** **Action** **Report** **&Patient** **Care** **Record,**Page [1](#bookmark1)

JTS APPROVED (Date)

(12Jul2018)-V4.1

**Event:**Date Time

Time Zone OL Oz

MM( )

Pt# of

Tail to Tail 〇YON

Leg# of

**9-Line:Time** Platform Dispatch Cat Assessed Cat

V

**Trauma** **MIST** **Report:**M=Mechanismoflnjury,.I=Injury,S=Signs &Symptoms,T=Treatments / Disease Diagnosis

M S

Comments

**Pickup:**Time Role Other Region Other Location

**Dropoff:**Time Role Other Region Other Location

**Capability** EMT-B EMT-I EMT-P EMT-FPC RN CRNA PA MD/DO Other

**Circulation-Hemorrhage** **Control**

Direct Pressure

Hemostatic Dressing

Kerlix Dressing

Pressure Dressing

Other

**Tourniquet**

Prior TQ

Reassess/tighten

OY

ON

ON/A

Time On CAT SOFT Other RUE LUE RLE LLE #

Time On CAT SOFTT Other RUE LUE RLE LLE #

Time On AAJT CRoC JETT SAM Other Junctiona #

TQ Comments

**Airway**

**Annotate** **Injuries**

Self NPA OPA Cric Trach ETT SGA Type

![](/media/202412//1733384222.2908602.jpeg)(AMP)utation

(BL)eeding

(B)urn %TBSA

(C)repitus

(D) eformity

(DG)Degloving

(E)cchymosis

(FX)Fracture

(GSW)Gunshot Wound

(H)ematoma

(IMP)Impaled Object

(LAC)eration

(P)ain

(PP)Peppering

(PW)Puncture Wound

(SQA)Subcut aneous Air

(TBI)Suspect

Othe

Tube Size Pos Confirmed BS Vis ]ETCO2

**O2** **Source** NC NRB BVM Vent LPM

**Intubated** Prior to transport By transportcrew **Suction** ETT Yaunker

**Breathing**

**Needle** **Decompression**

Time R Mid-ax Mid-clav

**Chest** **Equal** **Rise** **and** **Fall**

OY CN N/A

Time K L Mid-ax Mid-clav

**Respiratory** **Effort**

Time Mid-ax Mid-clav

Unlabored Agonal

Labored

Assisted

Time Mid-ax Mid-clav

**Chest** **Tube** ime

Vent Settings ime MIode Kate TV FiO2 PEEP PIP ETCO2

Initial

Chang

Change

**Circulation** **-Assessment** **Circulation** **-Resuscitation**

**Rhythm/Ectopy**

NSR SV]

ST VI

SB VF

PEA

Paced

Asystole

A-FIB

A-FLUT

Pulses

A,D,+1,+2,+3

RAD

BRAC

CAR

FEM

PED

TEMP

**Transfusion** **Indication**

Amputation

HR>120

SBP<90

**Blood** **Infusion** Time Component ABO/RH Unit Number Exp.Date Blood Age

**Peripheral**

anc K yd

Arm Ud

EJ ga

**IV** **Lines**

**l0** **Type/Site**

Fast-1 EZIO Other

Humerus R

Tibia R

Sternum

**Central** **Line** Location Arterial Lin

Triple lumen Wrist Cordis Groin

R

PREPARED BY

(Name,Rank&Title)

DEPARTMENT/SERVICE/CLINIC (Treating Unit)

DATE

PATIENTS IDENTIFICATION(Name:last,first,middle;grade;date;hospital or medical facility)

Last Name First Name MI

BR# Rank Unit pt Ca

SSN DOB Gender O M OF Allergy √Other

HISTORY/PHYSICAL X TREATMENT

DIAGNOSTIC STUDIES FLOW CHART

]OTHER EXAMINATION OREVALUATION ]OTHER,Specify

**DA** **FORM** **4700,FEB** **2003** **EDITION** **OF** **MAY** **78** **IS** **OBSOLETE.** **JTS** **TACEVAC** **AAR** **&PCR** **OP** **05** **(MCMR-SRJ)NOV** **2014** APD PE v1.01ES

**MEDICAL** **RECORD-SUPPLEMENTAL** **MEDICAL** **DATA**

For use of this form,see AR 40-66;the proponent agency is the Office of the Surgeon General

REPORT TITLE

**Tactical** **Evacuation** **After** **Action** **Report** **&Patient** **Care** **Record,P**age 2

JTS APPROVED (Date)

(12Jul2018)-V4.1

**Vital** **Signs**

Time HR

First

BP

/

RR

SpO2 ETCO2 Temp

F C

O O

AVPU

V

GCS:Eyes 1-4 Verbal 1-5 Motor 1-6 Total Pain 0-10

/ √

/ O O √

Last / ○ O √

PERRLA R Size (mm) L Size (mm)

Field Ultrasound Results Other Diagnostics

**Additional** **Interventions**

Time

**Foley**

Comment

Time

**Gastric** **Tube**

Oral □ Nasal Comment

**Protection** Eye Shield Protective Eyewear Right Left Commen

**Immobilization** ]C-Collar □ C-Spine □ Spine Board □ Pelvic Splint □ Pelvic Binder,Type

]Splint,Type/Location

**Warming** ]Hypothermia Prevention,Product

]Hypothermia Prevention,Product

**Other**

**Interventions**

**Medications** **and** **Fluids** Route=IM.IN.IO.IV.PO.PR.N.SO **Medications** **and** **Fluids** Route =IM,IN,IO,IV,PO,PR,SL,SQ

Time Drug/Fluid Dose Route

**Documents** **Received** TCCC Card Patient Chart None Othe

Narrative Summary of Care

**Enroute** **Care** **Provider**

Last Name First Name Rank

Capability V

Signature

V

Email PCR to:dha.jbsa.healthcare-ops.list.jts-prehospital@health.mil MM(\_)

PREPARED

(Signature

BY

&Title)

DEPARTMENT/SERVICE/CLINIC(Treating Unit)

DATE

PATIENTS IDENTIFICATION(Name:last,first,middle;grade;date;hospital or medical facility)

Last Name First Name MI

BR# Rank Unit pt Ca

SSN DOB Gender O M OF Allergy √Other

HISTORY/PHYSICAL TREATMENT

DIAGNOSTIC STUDIES FLOW CHART

]OTHER EXAMINATION OREVALUATION ]OTHER,Specify

**DA** **FORM** **4700,FEB** **2003** **EDITION** **OF** **MAY** **78** **IS** **OBSOLETE.** **JTS** **TACEVAC** **AAR** **&PCR** **OP** **05** **(MCMR-SRJ)NOV** **2014** APD PE v1.01ES

**TACTICAL** **EVACUATION-AFTER** **ACTION** **REPORT** **&PATIENT** **CARE** **RECORD**

Page 3

**IAW** **AR** **40-68(RAR)22** **May** **2009** **Paragraph** **3-7.This** **page** **is** **a** **quality** **assurance** **document.Do** **not** **file** **in** **medical** **rec**ords.

Helmet,Ballistic

Tactical Vest (IOTV) Eye Protection

Ear Protection

**Casualty's** **Protective** **Equipment** **(Check** **all** **worm)**

Plate Front Neck Protector (Back) Groin Shield Blast Gauge

Plate Back Throat Protector (Front) Pelvic Undergarment Tier 1 Blast Sensor Helmet

Plate Right Side Deltoid Right Pelvic Undergarment Tier 2 Blast Sensor Other

Plate Left Side Deltoid Left

**AAR** **Discussion** Event Date Tactical situation complicated care (Explain in discussion)

**Sustains**

**Improves**

![](/media/202412//1733384222.3288589.png)PATIENT'S IDENTIFICATION (Name:last,first,middle:grade;date;hospital or medical facllity

Last Name First Name MI

BR# Rank Unit

SSN DOB Gender C M O F Pt Cat

Date Allergy √Other

The National Defense Authorization Act for fiscal year 1987 (Public Law(PL)No.99-661),section 1102,Title 10,(10USC 1102)this

document was created by or for the DOD in a medical QA program and is confidential and privileged.PL 99-661 and subsequent

guidance predicated on this law(10 USC 1102)preclude

disclosure of,or testimony about,ary records or findings,

recommendations,evaluations,opinions,or actions taken as part of a QA program except in limited situations.Under the provisions of 10 USC 1102,this information is exempt from release in

accordance with Exemption 3 of the FOlA.Additional detailed information regarding the confidentiality of QA documents and records is contained in appendix B