Prepared by the Division of Emergency Medical Services

BLSBasic Training Course(Complete Dataset)

Medical Incident Report Form

Education Module for 2011

Prepared by the Division of Emergency Medical Services

Education Module Goals

• Train new EMS personnel

• Provide a review for experienced EMS personnel

Education Module Contents

• Basic information & general

instructions

• Aftercare Instructions Highlight

• 2011 MIRF dataset

Basic Information & General Instructions

Why the MIRF is Important

• Medical– The MIRF (both electronic and paper) is

part of the patient’s medical file.– The MIRF transfers information

between patient care providers.• Legal

– Confidentiality– Patient Refusal– MIRF Signature

Why the MIRF is Important (continued)

• Quality Review• Planning/Funding

– Medic unit placement, levy funding

• Research– Resuscitation Outcome Consortium

(ROC)– Aftercare Instructions Pilot Project

Components of a Good Report

• Completeness– All available information regarding

the incident or patient care should be recorded.

• Accuracy– Describe exactly what happened.

• Correct spelling• Legibility (on paper forms)

Components of a Good Report(continued)

•Narrative: use S.O.A.P format:– Subjective– Objective– Assessment– Plan

Basic Instructions• An electronic record is created by CAD/Dispatch for every

call/incident.

• When completing the paper (short) form in the field, use a ball point pen and press hard enough to mark through all copies.

• Complete the electronic record, verifying that the CAD information has been received, and augmenting this information where appropriate.

• Refer to your agency protocols regarding exceptions to completing the paper (short) form.

*******

• Agencies using the paper (long) form should complete a form for every call/incident.

Paper MIRF Pages

• Agency copy

• EMS copy

• Medical Review copy

• Patient copy

• Aftercare Instructions: The backer provides health information to patients.

Completing the MIRF

The person who provided primary care should:

• Sign your name• Print your name• Write your EMS number

• Follow the instructions on the back of the MIRF.

• Fill in patient’s name, and the date.• Read the statement slowly & clearly to the

patient. Ask if they understand what it says.

• Have the patient/guardian sign in the appropriate spots.

• If patient/guardian refuses or you are unable to obtain a signature, make a note to that effect.

• Obtain a signature from a witness and note their EMS agency affiliation or address.

Patient Refusal

Aftercare Instructions Highlight

Aftercare Instructions Highlight

The backer is to be given to ALL patients.

Aftercare instructions are located on the back of last page of the MIRF (both short and long form) for a variety of health conditions. CHECK ALL APPLICABLE boxes:

• Patient was Not Transported• Low Blood Sugar Information• High Blood Pressure Information• Falls• Community Resources Information

Aftercare Instructions Highlight (cont.)

• Not TransportedPatient left at scene or transported by a private

occupancy vehicle.

• Transported

Patient transported by BLS, ALS, or a private

ambulance.

Aftercare Instructions Highlight (cont.)

• Low Blood SugarPatient was treated for hypoglycemia and not

transported.

• High Blood Pressure

Patient with a systolic ≥ 160 OR diastolic ≥ 100.

• Falls

Aftercare Instructions Highlight (cont.)

• Community Resources – Can be offered to any patient in need of social services including:

• Caregiver & Disability Resources• Domestic Violence• Emergency Shelter• Financial Assistance for Rent or Utilities• Food & Clothing• Health Care & Support Groups• Legal Help

2011 MIRF Dataset

• Incident Data (in alphabetical order)

•Patient Data (in alphabetical order)

Incident Data

• Action Taken• Agency Incident Number• Aid Type

• Date Time Arrived on Scene• Date Time Dispatch Notified• Date Time In Service• Date Time Last Response Unit Leave

Scene• Date Time Primary PSAP Notified• Date Time Unit Notified by Dispatch• Date Time Unit Responded

Incident Data (Cont.)

• First Agency on Scene ID• First EMS Reporting Agency on

Scene• First Unit on Scene• Geocode

Incident Data (cont.)

• Incident Address• Incident City• Incident County• Incident State• Incident Type (NFIRS)• Incident Zip Code

Incident Data (cont.)

• Initial (Incident) Dispatch Code (IDC) • Location Type• Outside Agency Incident Number• Property Use (NFIRS)• Reporting Agency Number• Reporting Unit ID Number• Responding from Quarters• Responding in Fire District Code

Incident Data (cont.)

• Response Delay Type• Response Mode• Treatment Crew Member Name

Incident Data (cont.)

• Action Taken• Allergies• Date/Time Arrived at Patient’s Side• Date/Time Arrived at Treatment Facility

or Transfer Point• Date/Time Extrication is Completed• Date/Time Patient Left Scene• EMS ID Number of Person Completing

Form

Patient Data (Cont.)

• Flow Chart

Patient Data (Cont.)

TimeBlood PressurePulse RateRespiratory RateECG Rhythm*Oxygen*Pulse OximetryGlucometryIV fluids (liters) - ALS ONLYDC Shock/AED UsedMedications

• Flow Chart (cont.)

Patient Data (Cont.)

ECG Rhythm 01 Sinus Rhythm 02 Asystole 04 Other 11 Ventricular Fibrillation U0 Unknown

• Flow Chart (cont.)

Patient Data (Cont.)

Oxygen Mechanism1 Non-rebreather2 Nasal Cannula3 Bag Valve Mask4 Blow-By5 Other (see Narrative)6 BVM + ITD

The notes section of the flow chart can be used for notes or for extended flow chart information

• Glasgow Coma Eye Opening Component• Glasgow Coma Motor Response• Glasgow Coma Verbal Response• Glasgow Coma Score (GCS)

Patient Data (Cont.)

• Highest Level of Care Provided• Mass Casualty Incident• Medical Facility Contacted Name• Medical Person Contacted Name• MIRF Number

Patient Data (Cont.)

Patient Data (Cont.)

• Narrative

Use the S.O.A.P. format:SubjectiveObjectiveAssessmentPlan

• Onset of Symptoms• Patient Age, Units• Patient Date of Birth• Patient Street Address, City, County,

State, Phone• Patient First Name, Middle Initial, Last

Name• Patient Gender• Patient Health Care Provider, Phone

Patient Data (Cont.)

Patient Data (Cont.)

• Patient Mechanism Code (refer to the electronic pick list)

• Patient Medications Taken at Home• Patient Parent or Legal Guardian• Patient Suspected Alcohol or Drug

Use• Patient Type Code

• ProceduresCheck all boxes for procedures performed.

For procedures 12-31 only: write the procedure number and the EMS number of the person who performed the procedure

• Treatment Crew Member Number for Procedure

Patient Data (Cont.)

• Safety Equipment• Signature of Person Completing Form• Transport Agency Number• Transport Delay Type• Transport Destination• Transport Unit Number

Patient Data (Cont.)

2011 MIRF Changes

Incident Type (NFIRS)

Incident Type coding has been revised over the past few years. Here are some highlights of the current coding:

3117 - EMS call, Cancelled at Scene 3119 - EMS call, Unintentional medical alert activation3214 - EMS call, Vehicle accident with no injuries (use

if you want to create a patient record)3127 - EMS call, Flu-like symptoms324 - EMS call, Vehicle accident with no injuries

(standard NFIRS code-patient record not allowed)6113 - EMS call, Dispatched & cancelled enroute

Prepared by the Division of Emergency Medical Services

Medical Incident Report FormEducation Module for 2011

Prepared by the Division of Emergency Medical Services

THE END

BLS