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