Joint Patient Assessment and Tracking System
1. Incident Name {var Incident_Name}
Page
{var Page}
of {var Page1}
2. Operational Period
Date From: {var DateFrom}
To: {var DateTo}
Time From: {var TimeFrom} To: {var TimeTo}
3. Site name: {var Area}
Tracking #
Last Name
First Name
Sex
Example:
M =Male
F = Female
O = Other
DOB - Age
(numbers only)
Unaccompanied
Minor
Example
Y = Yes
N = No
Originating Site/ Facility Name
Patient Type
Example
1 = Federal Patient
2 = State & Local Patient
3 = Federal Non-Medical
4 = State & Local Non-Medical
Health Status
Example
1 = Critical
2 = Priority
3 = Routine
4 = Deceased
5 = N/A
Bed Type
Example
1 = Medical/Surgical
2 = Psychiatric
3 = Burns
4 = Pediatric
5 = Critical
6 = Unknown
Injury Nature
Notes
Disposition
Time Stamp
{var ID1}
{var Lastname1}
{var Firstname1}
{var Gender1}
{var DOB1}
{var DOB1}
{var Orgfaclty1}
{var PatientT1}
{var HeathStatus1}
{var Bedtype1}
{var Injurytype1}
{var Notes1}
{var Disp1}
{var Timestamp1}
{var ID2}
{var Lastname2}
{var Firstname2}
{var Gender2}
{var DOB2}
{var DOB2}
{var Orgfaclty2}
{var PatientT2}
{var HeathStatus2}
{var Bedtype2}
{var Injurytype2}
{var Notes2}
{var Disp2}
{var Timestamp2}
{var ID3}
{var Lastname3}
{var Firstname3}
{var Gender3}
{var DOB3}
{var DOB3}
{var Orgfaclty3}
{var PatientT3}
{var HeathStatus3}
{var Bedtype3}
{var Injurytype3}
{var Notes3}
{var Disp3}
{var Timestamp3}
{var ID4}
{var Lastname4}
{var Firstname4}
{var Gender4}
{var DOB4}
{var DOB4}
{var Orgfaclty4}
{var PatientT4}
{var HeathStatus4}
{var Bedtype4}
{var Injurytype4}
{var Notes4}
{var Disp4}
{var Timestamp4}
{var ID5}
{var Lastname5}
{var Firstname5}
{var Gender5}
{var DOB5}
{var DOB5}
{var Orgfaclty5}
{var PatientT5}
{var HeathStatus5}
{var Bedtype5}
{var Injurytype5}
{var Notes5}
{var Disp5}
{var Timestamp5}
{var ID6}
{var Lastname6}
{var Firstname6}
{var Gender6}
{var DOB6}
{var DOB6}
{var Orgfaclty6}
{var PatientT6}
{var HeathStatus6}
{var Bedtype6}
{var Injurytype6}
{var Notes6}
{var Disp6}
{var Timestamp6}
{var ID7}
{var Lastname7}
{var Firstname7}
{var Gender7}
{var DOB7}
{var DOB7}
{var Orgfaclty7}
{var PatientT7}
{var HeathStatus7}
{var Bedtype7}
{var Injurytype7}
{var Notes7}
{var Disp7}
{var Timestamp7}
{var ID8}
{var Lastname8}
{var Firstname8}
{var Gender8}
{var DOB8}
{var DOB8}
{var Orgfaclty8}
{var PatientT8}
{var HeathStatus8}
{var Bedtype8}
{var Injurytype8}
{var Notes8}
{var Disp8}
{var Timestamp8}
{var ID9}
{var Lastname9}
{var Firstname9}
{var Gender9}
{var DOB9}
{var DOB9}
{var Orgfaclty9}
{var PatientT9}
{var HeathStatus9}
{var Bedtype9}
{var Injurytype9}
{var Notes9}
{var Disp9}
{var Timestamp9}
{var ID10}
{var Lastname10}
{var Firstname10}
{var Gender10}
{var DOB10}
{var DOB10}
{var Orgfaclty10}
{var PatientT10}
{var HeathStatus10}
{var Bedtype10}
{var Injurytype10}
{var Notes10}
{var Disp10}
{var Timestamp10}
{var ID11}
{var Lastname11}
{var Firstname11}
{var Gender11}
{var DOB11}
{var DOB11}
{var Orgfaclty11}
{var PatientT11}
{var HeathStatus11}
{var Bedtype11}
{var Injurytype11}
{var Notes11}
{var Disp11}
{var Timestamp11}
{var ID12}
{var Lastname12}
{var Firstname12}
{var Gender12}
{var DOB12}
{var DOB12}
{var Orgfaclty12}
{var PatientT12}
{var HeathStatus12}
{var Bedtype12}
{var Injurytype12}
{var Notes12}
{var Disp12}
{var Timestamp12}
{var ID13}
{var Lastname13}
{var Firstname13}
{var Gender13}
{var DOB13}
{var DOB13}
{var Orgfaclty13}
{var PatientT13}
{var HeathStatus13}
{var Bedtype13}
{var Injurytype13}
{var Notes13}
{var Disp13}
{var Timestamp13}
{var ID14}
{var Lastname14}
{var Firstname14}
{var Gender14}
{var DOB14}
{var DOB14}
{var Orgfaclty14}
{var PatientT14}
{var HeathStatus14}
{var Bedtype14}
{var Injurytype14}
{var Notes14}
{var Disp14}
{var Timestamp14}
{var ID15}
{var Lastname15}
{var Firstname15}
{var Gender15}
{var DOB15}
{var DOB15}
{var Orgfaclty15}
{var PatientT15}
{var HeathStatus15}
{var Bedtype15}
{var Injurytype15}
{var Notes15}
{var Disp15}
{var Timestamp15}
{var ID16}
{var Lastname16}
{var Firstname16}
{var Gender16}
{var DOB16}
{var DOB16}
{var Orgfaclty16}
{var PatientT16}
{var HeathStatus16}
{var Bedtype16}
{var Injurytype16}
{var Notes16}
{var Disp16}
{var Timestamp16}
{var ID17}
{var Lastname17}
{var Firstname17}
{var Gender17}
{var DOB17}
{var DOB17}
{var Orgfaclty17}
{var PatientT17}
{var HeathStatus17}
{var Bedtype17}
{var Injurytype17}
{var Notes17}
{var Disp17}
{var Timestamp17}
{var ID18}
{var Lastname18}
{var Firstname18}
{var Gender18}
{var DOB18}
{var DOB18}
{var Orgfaclty18}
{var PatientT18}
{var HeathStatus18}
{var Bedtype18}
{var Injurytype18}
{var Notes18}
{var Disp18}
{var Timestamp18}
{var ID19}
{var Lastname19}
{var Firstname19}
{var Gender19}
{var DOB19}
{var DOB19}
{var Orgfaclty19}
{var PatientT19}
{var HeathStatus19}
{var Bedtype19}
{var Injurytype19}
{var Notes19}
{var Disp19}
{var Timestamp19}
{var ID20}
{var Lastname20}
{var Firstname20}
{var Gender20}
{var DOB20}
{var DOB20}
{var Orgfaclty20}
{var PatientT20}
{var HeathStatus20}
{var Bedtype20}
{var Injurytype20}
{var Notes20}
{var Disp20}
{var Timestamp20}
4. Submitted By
:
{var PreparedName}
Date: {var Date_Time} Time:
{var Time}
Location:
{var Facility}
Vers 0.6