HICS 259 – HOSPITAL CASUALTY/FATALITY REPORT<
PURPOSE: DOCUMENT THE NUMBER OF INJURIES AND FATALITIES
ORIGINATION: PATIENT TRACKING MANAGER
COPIES TO: COMMAND STAFF, SECTION CHIEFS, AND DOCUMENTATION UNIT LEADER
INSTRUCTIONS:
Enter complete information.
1. INCIDENT NAME If the incident is internal to the hospital, the name may be given by the hospital’s Incident Commander. If the incident affects the larger community, the name may be given by a local authority (e.g., fire department, local EOC, etc.).
2. DATE PREPARED Use the international standard date notation YYYY-MM-DD, where YYYY is the year, MM is the month of the year between 01 (January) and 12 (December), and DD is the day of the month between 01 and 31. For example, the fourteenth day of February in the year 2006 is written as 2006-02-14.
3. TIME PREPARED Use the international standard notation hh:mm, where hh is the number of complete hours that have passed since midnight (00-24) and mm is the number of complete minutes that have passed since the start of the hour (00-59). For example, 5:04 PM is written as 17:04. Use local time.
4. OPERATIONAL PERIOD DATE/TIME Identify the operational period during which this information applies. This is the time period established by the hospital’s Incident Commander, during which current objectives are to be accomplished and at the end of which they are evaluated. For example, a 12-hour operational period might be 2006-08-16 18:00 to 2006-08-17 06:00.
5. NUMBER OF CASUALTIES/FATALITIES For the operational period covered, record total numbers of adult and pediatric patients seen, admitted (specify bed type), discharged, transferred, expired, and waiting to be seen.
6. PREPARED BY (PATIENT TRACKING MANAGER) Use proper name.
7. FACILITY NAME Use when transmitting the form outside of the hospital.
WHEN TO COMPLETE: Prior to briefing in the next operational period.
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HICS 259 – HOSPITAL CASUALTY/FATALITY REPORT
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1. Incident Name:
{var IncidentName}
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2. Date:
{var Thedate} 3. Time:
{var TheTime}
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4. Operational Period # {var opperiod} |
Date From: |
{var DateFrom} |
Date To: |
{var DateTo} |
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Time From: |
{var TimeFrom} |
Time To: |
{var TimeTo} |
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5. Number Of Casualties/Fatalities |
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Adult |
Pediatric
(<18 years old) |
Total |
Comments |
Patients seen |
{var A1} |
{var A2} |
{var TOTAL1} |
{var Comment1} |
Waiting to be seen |
{var B1} |
{var B2} |
{var TOTAL2} |
{var Comment2} |
Admitted
|
{var C1} |
{var C2} |
{var TOTAL3} |
{var Comment3} |
Critical care bed |
{var D1} |
{var D2} |
{var TOTAL4} |
{var Comment4} |
Medical/surgical bed |
{var E1} |
{var E2} |
{var TOTAL5} |
{var Comment5} |
Pediatric bed |
{var F1} |
{var F2} |
{var TOTAL6} |
{var Comment6} |
Discharged |
{var G1} |
{var G2} |
{var TOTAL7} |
{var Comment7} |
Transferred |
{var H1} |
{var H2} |
{var TOTAL8} |
{var Comment8} |
Expired |
{var I1} |
{var I2} |
{var TOTAL9} |
{var Comment9} |
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6. Prepared by (Patient Tracking Manager):
{var Prepedbychief}
7. Facility Name :
{var Facility}
HICS 259
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