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May 17, 2004
PMS 423
Gray
Proof # 1
Job # 578765 pg1 bk.
NON-HOSPITAL DISPOSITION CODES:
THE RULE OF NINES
Estimation of Burned
Body Surface
(PERCENT)
001
002
003
NURSING HOME
OTHER MEDICAL FACILITY
RESIDENCE
TREATED BY THIS UNIT, TRANSPORTED
BY ANOTHER UNIT
REFUSED MEDICAL AID OR
TRANSPORT
CALL CANCELLED
STANDBY ONLY (NO PATIENT)
NO PATIENT FOUND
OTHER
004
005
006
007
008
010
Hospital Receiving Agent
(IF REQUIRED)
INFANT
ADULT
COMPLETE ON WHITE (AGENCY) COPY ONLY
SIGNATURE
Glasgow Coma Scale
REFUSAL OF TREATMENT/TRANSPORTATION
NEGATIVA A RECIBIR TRATAMIENTO/SER TRASLADADO
Eye
Opening
RELEASE
Spontaneous
To Voice
To Pain
EXONERACION DE RESPONSABILIDADES
None
Verbal
Response
COMPLETE ON WHITE (AGENCY) COPY ONLY
LLENE UNICAMENTE LA COPIA BLANCA (DE LA AGENCIA)
Oriented
Confused
Inappropriate Words
I hereby refuse (treatment/transport to a hospital) and I acknowledge that
such treatment/transportation was advised by the ambulance crew or
physician. I hereby release such persons from liability for respecting and
following my express wishes.
Incomprehensible Sounds
None
Motor
Response
Mediante la presente declaro que me niego a aceptar el tratamiento/traslado a un
hospital y reconozco asimismo que el medico o el personal de la ambulancia
recomendaron ese tratamiento/traslado. Consiguientemente, eximo a dichas personas
de toda responsabilidad por haber respetado y cumplido mid deseos expresos.
Obeys Command
Localizes Pain
Withdraw (pain)
Flexion (pain)
Extension (pain)
None
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1
Patient's Best Verbal Response
Arouse patient with voice or
painful stimulus.
Patient's Best Motor Response
Response to command or
painful stimulus.
:3-15
ICD DIAGNOSTIC CODE
Total GCS Score
Signed:
Firma:
Witness:
Testigo:
INSURANCE
ID #
CARRIER
1 អ MEDICARE
អ YES
WAS THIS A WORKER'S COMPENSATION INJURY:
អ NO
2 អ MEDICAID
BLUE
3 អ CROSS
COMMERCIAL
4 អ INSURANCE
5 អ SELF PAY
INSURANCE CODE
PATIENT'S EMPLOYER:
)
PHONE (
)
PHONE (
EMPLOYER'S ADDRESS:
RESPONSIBLE PARTY:
ADDRESS:
(ZIP:
)
RELATION:
578765
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