Hics 260 – patient evacuation tracking form




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HICS 260 – PATIENT EVACUATION TRACKING FORM

1. DATE


2. UNIT


3. PATIENT NAME


4. AGE

5. MR #

6. DIAGNOSIS (-ES)


7. ADMITTING PHYSICIAN

8. FAMILY NOTIFIED
 YES  NO CONTACT INFORMATION:


9. ACCOMPANYING EQUIPMENT (CHECK THOSE THAT APPLY

 Hospital Bed


IV Pumps


 Isolette/Warmer


 Foley Catheter


 Gurney


 Oxygen


Traction


 Halo-Device


Wheel Chair


 Ventilator


Monitor


 Cranial Bolt/Screw


 Ambulatory


 Chest Tube(s)


 A-Line/Swan


IO Device


 Other


 Other


 Other


 Other


ISOLATION  YES  NO

TYPE

REASON

10. DEPARTING LOCATION

11. ARRIVING LOCATION

ROOM#

TIME

ROOM #

TIME


ID Band Confirmed

 YES  NO



By:

ID Band Confirmed

 YES  NO



By:


Medical Record Sent  YES  NO

Medical Record Sent  YES  NO

Addressograph Sent  YES  NO

Addressograph  YES  NO

Belongings  with Patient  Left in Room  None

Belongings Received  YES  NO

Valuables  with Patient  Left in Safe  None

Valuables  YES  NO

Medications  with Patient  Left on Unit  to Pharmacy

Medications Received  YES  NO

PEDS/INFANTS

Bag/Mask with Tubing Sent  YES  NO

Bag/Mask with Tubing Received  YES  NO

Bulb Syringe Sent  YES  NO

Bulb Syringe Received  YES  NO

12. TRANSFERRING TO ANOTHER FACILITY

TIME TO STAGING AREA

TIME DEPARTING TO RECEIVING FACILITY

DESTINATION

TRANSPORTATION  Ambulance Unit Helicopter  Other:

ID BAND CONFIRMED  YES  NO BY: (please print)


DEPARTURE TIME


13. FACILITY NAME




PURPOSE: Document details and account for patients transferred to another facility. ORIGINATION: Medical Care Branch Director

ORIGINAL TO: Patient COPIES TO: Patient Tracking Manager and Departing Location

HICS 260


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