Emergency Preparedness

Appendix O.12 HICS 255 MASTER PATIENT EVACUATION TRACKING

1. Incident Name

2. Operational Period (# ) DATE:

FROM: _______________________________________________ TO: ________________________________________________ TIME: FROM: _______________________________________________ TO: ________________________________________________

3. Patient Evacuation Information PATIENT NAME

Medical Record #

Evacuation Triage Category IMMEDIATE DELAYED MINOR

Mode of Transport CCT ALS BLS VAN BUS CAR AIRCRAFT

Accepting Hospital or Location

Time hospital contacted & report given

Disposition DISCHARGE/ TRANSFER/MORGUE

Transfer Initiated (Time/Transport Co./ #)

Medical Record Sent YES NO

Medication Sent YES NO

Expired (time)

Family Notified YES NO

Arrival Confirmed YES NO

Admit Location FLOOR ICU ER MORGUE

Medical Record #

Evacuation Triage Category IMMEDIATE DELAYED MINOR

Mode of Transport CCT ALS BLS VAN BUS CAR AIRCRAFT

PATIENT NAME

Accepting Hospital or Location

Time hospital contacted & report given

Disposition DISCHARGE/ TRANSFER/MORGUE

Family Notified YES NO

Arrival Confirmed YES NO

Admit Location FLOOR ICU ER MORGUE

Transfer Initiated (Time/Transport Co./ #)

Medical Record Sent YES NO

Medication Sent YES NO

Expired (time)

Medical Record #

Evacuation Triage Category IMMEDIATE DELAYED MINOR

Mode of Transport CCT ALS BLS VAN BUS CAR AIRCRAFT

PATIENT NAME

Accepting Hospital or Location

Time hospital contacted & report given

Disposition DISCHARGE/ TRANSFER/MORGUE

Transfer Initiated (Time/Transport Co./ #)

Medical Record Sent YES NO

Medication Sent YES NO

Expired (time)

Family Notified YES NO

Arrival Confirmed YES NO

Admit Location FLOOR ICU ER MORGUE

Medical Record #

Evacuation Triage Category IMMEDIATE DELAYED MINOR

Mode of Transport CCT ALS BLS VAN BUS CAR AIRCRAFT

PATIENT NAME

Accepting Hospital or Location

Time hospital contacted & report given

Disposition DISCHARGE/ TRANSFER/MORGUE

Transfer Initiated (Time/Transport Co./ #)

Medical Record Sent YES NO

Medication Sent YES NO

Expired (time)

Family Notified YES NO

Arrival Confirmed YES NO

Admit Location FLOOR ICU ER MORGUE

4. Prepared by

PRINT NAME:

________________________________________________________________________________

SIGNATURE:

_________________________________________________________________________

DATE/TIME:

_________________________________________________________________________________

FACILITY: ____________________________________________________________________________