Medical Incident Report Form
Education Module for 2011
BLS
Basic Training Course
(Complete Dataset)
Prepared by the Division of Emergency Medical Services
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
Patient Refusal
• 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.
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 Transported
Patient 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 Sugar
Patient 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
Incident Data (Cont.)
•
•
•
•
Date Time
Date Time
Date Time
Date Time
Scene
• Date Time
• Date Time
• Date Time
Arrived on Scene
Dispatch Notified
In Service
Last Response Unit Leave
Primary PSAP Notified
Unit Notified by Dispatch
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
Incident
Incident
Incident
Incident
Incident
Address
City
County
State
Type (NFIRS)
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
Patient 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
Time
Blood Pressure
Pulse Rate
Respiratory Rate
ECG Rhythm*
Oxygen*
Pulse Oximetry
Glucometry
IV fluids (liters) - ALS ONLY
DC Shock/AED Used
Medications
Patient Data (Cont.)
• Flow Chart (cont.)
ECG Rhythm
01 Sinus Rhythm
02 Asystole
04 Other
11 Ventricular Fibrillation
U0 Unknown
Patient Data (Cont.)
• Flow Chart (cont.)
Oxygen Mechanism
1 Non-rebreather
2 Nasal Cannula
3 Bag Valve Mask
4 Blow-By
5 Other (see Narrative)
6 BVM + ITD
The notes section of the flow chart can be used for notes or for
extended flow chart information
Patient Data (Cont.)
•
•
•
•
Glasgow
Glasgow
Glasgow
Glasgow
Coma
Coma
Coma
Coma
Eye Opening Component
Motor Response
Verbal Response
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.)
• Narrative
Use the S.O.A.P. format:
Subjective
Objective
Assessment
Plan
Patient Data (Cont.)
•
•
•
•
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 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
Patient Data (Cont.)
• Procedures
Check 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
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 activation
3214 - EMS call, Vehicle accident with no injuries (use if you
want to create a patient record)
3127 - EMS call, Flu-like symptoms
324 - EMS call, Vehicle accident with no injuries (standard
NFIRS code-patient record not allowed)
6113 - EMS call, Dispatched & cancelled enroute
Medical Incident Report Form
Education Module for 2011
BLS
THE END
Prepared by the Division of Emergency Medical Services
Prepared by the Division of Emergency Medical Services