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On-Scene Physician Form

Iredell County Emergency Medical Services System would like to thank you for your effort and assistance.  Please be advised that the EMS professionals are operating under strict guidelines established by their Medical Director and the State of North Carolina.  As a licensed physician, you may assume medical care of the patient.  In order to do so, you will need to:

1.       Receive approval to assume the patient’s medical care from the on-duty emergency department physician at Iredell Memorial Hospital, Davis Regional Medical center or Lake Norman Regional Medical Center.

2.       Show proper identification including a current North Carolina Medical Board Registration Card.

3.       Accompany the patient to the hospital.

4.       Carry out interventions that do not conform to the ICEMS System Protocols.  The EMS personnel will not perform interventions that are not included in their protocols.

5.       Sign all orders on the Signature Sheet associated with the Patient Care Report.

6.       Assume all medicolegal responsibility for all patient care activities until care is transferred at another physician at the destination hospital.

7.       Complete the “Assumption of Medical Care” section below.

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Assumption of Medical Care

I, ________________________, MD; License# _____________________, have assumed

 authority and responsibility for the patient management of __________________________.

                               (Patient’s Name)

I understand that I must accompany the patient to the Emergency department.  I further understand that all EMS personnel must follow North Carolina EMS Advanced Life Support Rules and Regulations as well as the Iredell County Emergency Medical Services System protocols.

________________________, MD            Date: _______________ Time: _____________

________________________, EMS          _______________________________, Witness