HICS 259 – HOSPITAL CASUALTY/FATALITY REPORT
PURPOSE: The HICS 259 - Hospital Casualty/Fatality Report is used to record the total numbers of adult and pediatric patients seen, admitted (by bed type), discharged, transferred, expired, and waiting to be seen for each operational period.
ORIGINATION: The HICS 259 is prepared by the Planning Section Patient Tracking Manager or team prior to the Operations Briefing in the next operational period.
COPIES TO: Copies are distributed to the Command Staff, Section Chiefs, and the Documentation Unit Leader.
NOTES: If additional pages are needed, use a blank HICS 259 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.
INSTRUCTIONS
1 Incident Name
Enter the name assigned to the incident.
2. Date of Report
3. Time of Report
4. Operational Period
Enter the start date (m/d/y) and time (24-hour clock) and end date and time for the operational period to which the form applies.
5. Number of Casualties / Fatalities
Patients seen
Enter total number of patients seen in either the adult or pediatric column.
Admitted
Enter total number of patients admitted in either the adult or pediatric column.
Critical Care
Enter total number of patients admitted in either the adult or pediatric column.
Medical / Surgical
Enter total number of patients admitted in either the adult or pediatric column.
Other
Enter other needed categories (i.e., burn, pediatric, labor and delivery, forensic, psychiatric) in either the adult or pediatric column.
Discharged
Enter total number of patients discharged in either the adult or pediatric column.
Transferred
Enter total number of patients transferred in either the adult or pediatric column.
Morgue Enter total number of patients expired in either the adult or pediatric column.
Waiting to be seen
Enter total number of patients still waiting to be seen by physician in either the adult or pediatric column.
6. Prepared by
Enter the name and signature of the person preparing the form. Enter date (m/d/y), time prepared (24-hour clock), and facility.
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