HICS 254 DISASTER VICTIM / PATIENT TRACKING – 1. Incident Name 2. Operational Period (# ) DATE: FROM: TO: TIME: FROM: _ TO: 3. Area (Triage or Specific Treatment Area) DISPOSITION / TIME TRIAGE CATEGORY (D) DISCHARGE (A) DOB / AGE NAME IMMEDIATE SEX ADMIT FIELD TAG MEDICAL RECORD (LAST NAME, FIRST NAME) LOCATION / TIME OF PROCEDURES DELAYED (M/F) NUMBER NUMBER (S) SURGERY MINOR (CT, X-RAY, ETC.) EXPECTANT (T) TRANSFER EXPIRED (M) MORGUE 4. Prepared by PRINT NAME: SIGNATURE: DATE/TIME: FACILITY: _ HICS 254 | Page 1 of 1 Purpose: Records the triage, treatment, and location of victims/patients Origination: Patient Tracking Manager or team Copies to: Situation Unit Leader, Patient Registration Unit Leader, Planning Section Patient Tracking Manager, Medical Care Branch Director, and Documentation Unit Leader
HICS 254 – DISASTER VICTIM / PATIENT TRACKING 1. Incident Name 2. Operational Period (# ) DATE: FROM: TO: TIME: FROM: _ TO: 3. Area (Triage or Specific Treatment Area) FIELD TAG NUMBER MEDICAL RECORD NUMBER NAME (LAST NAME, FIRST NAME) SEX (M/F) DOB / AGE TRIAGE CATEGORY IMMEDIATE DELAYED MINOR EXPECTANT EXPIRED LOCATION / TIME OF PROCEDURES (CT, X-RAY, ETC.) DISPOSITION / TIME (D) DISCHARGE (A) ADMIT (S) SURGERY (T) TRANSFER (M) MORGUE 4. Prepared by PRINT NAME: SIGNATURE: DATE/TIME: FACILITY: _ Purpose: Records the triage, treatment, and location of victims/patients Origination: Patient Tracking Manager or team Copies to: Situation Unit Leader, Patient Registration Unit Leader, Planning Section Patient Tracking Manager, Medical Care Branch Director, and Documentation Unit Leader HICS 254 | Page 1 of 1
HICS-2014-Forms.docx