Cardiac Data Report

01 Facility & Patient Information

Facility *

Patient ID

Wrist Band ID

Date of Birth *

Age *

Gender *

Insurance

Race

Hispanic or Latino Ethnicity

02 Cardiac Arrest

Cardiac Arrest Outside Healthcare Facility? *

Arrest After Arrival of EMS?

Arrest Witnessed?

Bystander CPR?

03 Aspirin & ECG

Aspirin Given Within 24 Hours? *

In Field or In Hospital?

If No, Reason

Pre-hospital EKG done?

04 Transportation & Arrival

Means of Transportation *

EMS First Medical Contact (Date/Time)

Transferred from Outside Facility?

Location of First Evaluation *

Destination Arrival Date/Time *

Date/Time of Initial Destination ECG *

05 STEMI & Intervention

STEMI or STEMI Equivalent on Initial ECG? *

If Yes, 1st ECG or Subsequent?

Date/Time of Subsequent ECG

EMS STEMI Field Activation Date/Time

Cath Lab Activation Date/Time

PCI Performed? *

Device Time (Date/Time)

Thrombolytics Administered?

Thrombolytic Therapy Date/Time

06 Discharge

Discharge Date/Time *

Disposition *

All submitted data is transmitted securely and stored in the CENTEX RAC reporting system. Fields marked * are required.

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