TACEVAC AAR 和 PCR 说明

**1. BACKGROUND and PURPOSE**

a. Tactical Evacuation (TACEVAC) Pre-Hospital, Pre-Medical Treatment Facility (pre-MTF), or intra-MTF

documentation of medical interventions by TACEVAC medical personnel is critical to ensuring continuity of care and providing meaningful analyses of medical interventions, techniques, tactics, and procedures rendered during transport.

b. As medical providers, it is critically important to document patient care for follow on providers in order to achieve the best patient outcomes. Additionally, well documented care can improve not only individual care, but as part of a Process Improvement system, good documentation can identify places where casualty care can be improved on a

system-wide level.

c. Use of the DA Form 4700 OP3, Tactical Evacuation (TACEVAC) After Action Report (AAR) and Patient Care

Record (PCR) will allow for individual care improvement as well as a method for process improvement and quality assurance for TACEVAC medical providers. It is designed specifically for use by TACEVAC medical personnel in order to document all evaluation and care provided for casualties.

**2. POLICY**

a. Commanders will ensure that all TACEVAC providers use the PCR to document TACEVAC care. Such care relates to both battle and non-battle injuries.

b. Once completed, the PCR will be included with the patient’s medical record and the trauma system’s trauma

registry. TACEVAC unit commanders must establish a clear process to ensure entry of the medical information recorded in the electronic health record through the Joint Trauma System.

c. TACEVAC medical personnel will complete all entries as fully as possible.

d. Detailed instructions for preparing the PCR are provided in Table 1 and Table 2.

e. All abbreviations authorized for use in DoD health records or DoD trauma registries may also be used on the PCR.

f. Ideally, all entries on the PCR will be made electronically after care is provided, with digital signatures. Manual entries maybe made using anon-smearing pen or marker.

g. All entries on the PCR should be printed clearly, including the TACEVAC provider’s name.

**Table 1**

**DA Form 4700 Tactical Evacuation After Action Report and Patient Care Record Instructions for completing Footer of Page 1 & 2**

**Item**

**Instruction**

**Demographics/Injury/Evacuation**

Last Name, First Name, MI

Record patient’s name (Last, First and Middle Initial).

Battle Roster #

Record first letter of patient’s first name, then first letter of patient’s lastname, then record the last four numbers of patient’s Social Security number. For

example, John Doe 123-12-1234 is Battle Roster # ‘JD1234 ’.

Rank

Record patient’srank.

Unit

Record patient’sunit name.

Pt Cat

Select the patient’s category from the dropdown list. Choices are: USA

(U.S. Army), USAF (U.S. Air Force), USMC (U.S. Marine Corp), USN (U.S. Navy), USCG (U.S. Coast Guard), USPHS (U.S. Public Health Services),

Civilian-Local (includes Host Nation), Civilian Other (includes Host Nation

Police), Contractor, EPW (Enemy Prisoner of War), NATO-Coalition (joining military forces), NonNATO-Coalition (opposing military forces), or Other.

SSN

Record patient’s Social Security number or ID number.

DOB

Record patient’s Date OfBirth.

Gender

Mark an ‘X’ on the patient’s gender (Male (M) or Female (F)).

Allergy

Select patient’s known drug allergies from dropdown list. Choices are: NKDA (no known drug allergies), Opiates, Penicillin, Sulphur, or Other. If ‘Other’ is selected, record specific allergy on ‘Other’ adjacent line.

**Note**: This form, DA Form 4700 Tactical Evacuation After Action Report and Patient Care Record, is intended for Treatment documentation. Treatment is always marked with an ‘X’ and is not editable.

**Table 2**

**DA Form 4700 Tactical Evacuation After Action Report and Patient Care Record Instructions for completing Page 1**.

**Item**

**Instruction**

Event Date/Time

Date. Record the date of injury. Select date from calendar popup or manually type the date (mmddyyyy). Date auto formats with slashes.

Time. Record 24-hour time of injury (hhmm). Time auto formats hh:mm.

Time Zone

Mark an ‘X’ (L (Local) or Z (Zulu)) for time zone in which all times are recorded on this form

MM

Record the medical mission number, for example (S)01-16A. MM auto populates on page 2.

Pt # of

Record the patient’s number (first blank) of the total number of patients (second blank) for this evacuation.

Tail to Tail

Mark an ‘X ’ Y (yes) or N (no) for tail-to-tail evacuation.

Leg # of

Record the leg number (first blank) of the total number of legs (second blank) for this evacuation.

9-Line

Time. Record 24-hour time of 9-Line (hhmm) in the same time zone as marked in

‘Time Zone’ above. Time auto formats hh:mm.

Platform. Select the platform (aircraft) from the dropdown list.

Dispatch Cat. Select the level of urgency: urgent,priority, or routine, from the dropdown list.

Assessed Cat. Select the level of urgency: urgent,priority, or routine, from the dropdown list.

Disease Diagnosis

If the evacuation is due to disease, record the diagnosis of the disease. Record N/A if evacuation is not due to disease.

MIST Report

M. Select the dominant/primary Mechanism of injury from the dropdown list. If

more than one Mechanism, specify additional mechanisms in Comments.

I. Select the type of Injury from the dropdown list. S. Record the patient’s Signs and Symptoms.

T. Record the Treatment given to the patient.

Comments

Record clarifying 9-Line comments.

Pickup

Time. Record 24-hour time of pickup. Time auto formats hh:mm.

Role. Select the Role (level of care) from which the patient is picked up, from the dropdown list:1-POI (Point of Injury), 1-Aid Station, Role 2, Role 3, Role 4, Other. If ‘Other’, record the level of care/facility.

Region. Select the region in which the pickup occurred. If ‘Other’, record the region name.

Location. Record the specific geographic location of the pickup.

Dropoff

Time. Record 24-hour time of dropoff. Time auto formats hh:mm.

Role. Select the Role (level of care) at which the patient is dropped off, from the dropdown list: 1-Aid Station, Role 2, Role 3, Role 4, Other. If ‘Other’, record the level of care/facility.

Region. Select the region in which the dropoff occurred. If ‘Other’, record the region name.

Location. Record the specific geographic location of the dropoff.

Capability

Mark an ‘X’ for each capability present for this patient/mission. If ‘Other’, record the other capability present.

**Circulation-Hemorrhage Control**

Direct Pressure

Hemostatic Dressing Kerlix Dressing

Pressure Dressing Other

Mark an ‘X’ for each type of dressing used to control bleeding. If ‘Other ’ type of dressing, record the type.

Prior TQ: Reassess/tighten

Mark an ‘X’ (Y (yes), N (no), or N/A (not applicable) for previously applied tourniquet assessment/adjustment.

**Table 2**

**DA Form 4700 Tactical Evacuation After Action Report and Patient Care Record Instructions for completing Page 1**.

**Item**

**Instruction**

Tourniquet

Time On. Record 24-hour time (hhmm) of all new tourniquet applications in the same timezone as marked in ‘Time Zone’ above. Time auto formats hh:mm.

Extremity Tourniquet.

Mark an ‘X’ on all types of extremity tourniquet applied, CAT (Combat

Application Tourniquet), SOFTT (Special Operations Forces Tactical

Tourniquet) and/or Other. If ‘Other’, record the extremity tourniquet type.

Mark an ‘X’ on all locations, RUE (patient’sright arm (right upper extremity), LUE (patient’s left arm (left upper extremity), RLE (patient’sright leg

(right lower extremity), LLE (patient’s left leg, (left lower extremity). Junctional Tourniquet.

Mark an ‘X’ on type of truncal/junctional tourniquet applied, AAJT

(Abdominal Aortic Junctional Tourniquet), CRoC (Combat Ready

Clamp), JETT (Junctional Emergency Treatment Tool), SAM (Junctional tourniquet by SAM Medical Products), and/or Other. If ‘Other’, record the junctional tourniquet type.

**Note**: Type of junctional tourniquet inherently describes tourniquet location. #. Record the number of tourniquets applied at the documented ‘Time On’ time.

TQ Comments

Record clarifying notes for tourniquets.

**Airway**

Treatment Types

Mark an ‘X’ for all types of airway treatment given. Self (none, patient breathes without assistance), NPA (nasopharyngeal airway), OPA (oropharyngeal

airway), Cric (cricothyroidotomy), Trach (tracheotomy), ETT (endotracheal tube), SGA (supraglottic airway).

Type. Record type of supraglottic airway treatment.

Tube

Size. Record the size of tube.

Pos @ . Record the position (first blank) and select the Gums, Nare, or Teeth (second blank) from the dropdown list.

Confirmed

Mark an ‘X’ for all methods used to confirm breathing, BS (breath sounds), Vis (visualization/chest rise), ETCO2 (End Tidal CO2 device).

O2 Source

Mark an ‘X’ for all sources used to deliver oxygen, NC (nasal cannula and nasal catheters), NRB (non-rebreather mask), BVM (bag valve mask), Vent

(mechanical ventilator).

LPM. Record flow of oxygen in liters per minute.

Intubated

Mark an ‘X’ for Prior to transport (intubation occurred prior to transport); By transport crew (intubation occurred during transport).

Suction

Mark an ‘X’ for ETT (Endotracheal tube), Yaunker (Oral suction tube).

**Annotate Injuries**

Annotate Injuries

Record type of injury and location on the body map. Position the cursor over the location of the injury and type acronym for dominant injuries. For example, ‘GSW’ for gunshot wound.

**Note**: Press the Tab key (or Shift+Tab) to position the cursor over the location. The cursor moves from Anterior Head to Posterior Head, Posterior

Back/Buttocks to Anterior Chest/Abdomen, and then right arm, left arm, right leg, and left leg.

**Breathing**

Needle Decompression

Time. Record 24-hour time of all needle decompressions (ND) in the sametime zone as marked in ‘Time Zone’ above.

Mark an ‘X’ for R (right), L (left), Mid ax ( mid axillary), Mid clav (mid clavicle) locations of NDs.

Chest Tube

Time. Record 24-hour time of chest tube insertion in the same time zone as marked in ‘Time Zone’ above.

Mark an ‘X’ for R (right) and/or L (left) chest tube location.

**Table 2**

**DA Form 4700 Tactical Evacuation After Action Report and Patient Care Record Instructions for completing Page 1**.

**Item**

**Instruction**

Chest Equal Rise and Fall

Mark a ‘![](/media/202412//1733384314.32386.png)’for Y (yes), N (no) or N/A (not applicable) of equal chest rise and fall.

Respiratory Effort

Mark an ‘X’ for Unlabored, Labored, Agonal, and Assisted respiratory effort.

Vent Settings

Time. Record 24-hour time of initial and subsequent vent settings in the same timezone as marked in ‘Time Zone’ above.

Record initial and subsequent vent setting values for Mode, Rate, TV, FiO2, PEEP, PIP and ETCO2.

**Circulation Assessment**

Rhythm/Ectopy

Mark an ‘X’ for NSR (normal sinus rhythm), SVT (supraventricular tachycardia), ST (sinus tachycardia), VT (ventricular tachyarrhythmias), SB (sinus

bradycardia), VF (ventricular fibrillation), PEA (pulseless electrical activity), Paced, Asystole, A-Fib (atrial fibrillation), A-FLUT (atrial flutter) of heart

rhythm/ecytopy.

Pulses

Select A, D, +1, +2, +3 from the dropdown list for RAD, BRAC, CAR, FEM, PED, TEMP.

**Circulation Resuscitation**

Transfusion Indication

Mark an ‘X’ for Amputation, HR (heart rate) > 120, SBP (systolic blood pressure) < 90. Mark all that apply.

Blood Infusion

Time. Record 24-hour time infusion began in the same time zone as marked in ‘Time Zone’ above.

Component. Select the infusion component, FDP (Freeze Dried Plasma), FFP (Fresh Frozen Plasma), PRBC (Packed Red Blood Cells), or Whole Blood from the dropdown list.

ABO/RH. Select A+, A-, AB+, AB-. B+, B-, O+, or O- bloodtype from the dropdown list.

Unit Number. Record the blood unit number, for example W012014000129P.

Exp. Date. Record the blood expiration date. Select date from calendar popup or

manually type the date (mmddyyyy). Date auto formats with slashes. Blood Age. Record the age of blood.

IV Lines

Peripheral. Mark an ‘X’ for R (right), L (left) Hand; R (right), L (left) Arm; R (right), L (left) EJ (external jugular) of all intravenous line sites. Record the gauge of all lines.

IO Type/Site.

Mark an ‘X ’ for Fast-1, EZ IO intraosseous (IO) types used. If ‘Other’, record the IO type used.

Mark an ‘X ’ for (R (right), L (left) Humerus; (R (right), L (left) Tibia, Sternum IO sites.

Central Line. Mark an ‘X’ for Triple lumen and/or Cordis central lines. Select

Fem-R, Fem L, IJ-R, IJ-L, Subclav-R, Subclav-L site from the dropdown list.

Arterial Line. Mark an ‘X’ for R (right), L (left) Wrist; R (right), L (left) Groin sites.

**Prepared By/Department/Date**

Prepared By

Record your name, rank and title, the person who completed the form.

Department/Service/Clinic

Record the department, service, and/or clinic that provided treatment. This entry auto populates entry on page 2.

Date

Record the date the form was completed. Select date from calendar popup or manually type the date (mmddyyyy). Date auto formats with slashes. The date auto populates on page 2.

**Table 3**

**DA Form 4700 Tactical Evacuation After Action Report and Patient Care Record Instructions for completing Page 2**.

**Item**

**Instruction**

**Vital Signs**

Vital Sign Time/Values

Time. Record 24-hour time (hhmm) vital signs were obtained, in the sametime zone as marked in ‘Time Zone’ page 1. Time auto formats hh:mm.

Values. Record values for all known vital signs.HR (Heart Rate). BP (Blood

Pressure): record the systolic value in first blank and diastolic value in second blank. Alternatively, record the P value. RR (Respiratory Rate). SpO2

(Oxygen saturation level). ETCO2 (End Tidal CO2). Temp (Temperature) and select F (Fahrenheit) or C (Celsius). AVPU, select patient’s level of

consciousness: Alert, Verbal, Pain or Unresponsive. GCS, Eyes, Verbal, and Motor, select a value from the dropdown list, with 1 being the worst score,

and 4, 5, or 6 respectively being the best score. GCS Total auto calculates the sum. 15 is the best score. Pain, select the patient’s level of pain from the

dropdown list, with 0 being no pain, and 10 being the worst pain.

PERRLA

Mark an ‘X’ for R (right eye) and/or L (left eye) pupils equal, round, reactive to light and accommodation. Then record size in mm.

Field Ultrasound Results.

Record ultrasound results.

Other Diagnostics.

Record any other diagnostic results not otherwise specified.

**Additional Interventions**

Time

Record 24-hour time (hhmm) of each intervention in the same time zone as marked in ‘Time Zone’ page 1. Time auto formats hh:mm.

Foley

Record comments specific to Foley.

Gastric Tube

Mark an ‘X’ for Oral and/or Nasal. Record comments specific to gastric tube.

Protection

Mark an ‘X’ for Eye Shield, Protective Eyewear and for R (right), L (left) eye. Record comments specific to eye protection.

Immobilization

Mark an ‘X’ for C-Collar, C-Spine, Spine Board, Pelvic Splint, Pelvic Binder

and/or Splint. If Pelvic Binder, record the type. If Splint, record type and location.

Warming

Mark an ‘X’ for hypothermia prevention administered. Record the product type/name.

Other Interventions

Record other interventions not otherwise specified.

**Medications and Fluids**

Medications and Fluids

Record name, dose, route, and 24-hour time of medications and fluids given.

Documents Received

Mark an ‘X’ for all documents received with the patient. TCCC (TCCC, DD1380 Tactical Combat Casualty Care Card), Patient Chart, None. If Other

documentation was received, record the type, document title and/or description.

**Narrative Summary**

Narrative Summary

Record a summary of the care provided for the medical record. Do not include items documented previously. Do not include classified information.

**Enroute Care Provider**

Provider Name

Record the name (last, first) rank of the enroute care provider(s). Select the

provider’s capability from the dropdown list (EMT-B, EMT-I, EMT-P, EMT- FPC, RN, CRNA, PA, MD/DO).

Provider Signature

Provider(s) digitally sign the form, recording the provider’s name, capability, date and time of signature.

**WARNING!** Signature locks and prevents edits to Provider Name information.

**Prepared By/Department/Date**

Prepared By

The person who prepared the form digitally signs, recording his/her name, capability, date and time of signature.

**WARNING!** Signature locks and prevents edits to entire form.

Department/Service/Clinic

Type/Record the department, service, and/or clinic that provided treatment. Auto populates field on page1/2.

**3. ISSUANCES**

a. DoDI 6490.03, Deployment Health

b. DoDI 6040.45, Service Treatment Record (ST) and Non-Service Treatment Records (NSTR)

c. DHB Memorandum Tactical Evacuation Care Improvements within the Department of Defense 2011-03 (August 8, 2011)

d. AR 40-66, Medical Record Administration and Healthcare Documentation