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BED REQUEST [BEDREQ]

Use to request beds for patients when the medical group record can not be used. Reference: FM 8-10-5.

LINE 1 — DATE AND TIME______________________________(DTG)

LINE 2 — UNIT________________________________________(Unit Making Report)

LINE 3 — REQUESTOR__________________________________(Name or Designator of Requesting Element With Patients Requiring Beds)

LINE 4 — LOCATION___________________________________(UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator)

LINE 5 — PATIENTS____________HYPHEN_____TOTAL_____(Number of Litter (After PATIENTS), Ambulatory (After HYPHEN), and All (After TOTAL) Patients Requiring Beds)

LINE 6 — MEDICAL (MM)_______HYPHEN_____TOTAL_____(Number of Litter (After MM), Ambulatory (After HYPHEN), and All (After TOTAL) MM Requiring Beds)

LINE 7 — PSYCHIATRIC (MP)___HYPHEN_____TOTAL_____(Number of Litter (After MP), Ambulatory (After HYPHEN), and All (After TOTAL) MP Requiring Beds)

LINE 8 — SURGERY (SS)________HYPHEN_____TOTAL_____(Number of Litter (After SS), Ambulatory (After HYPHEN), and All (After TOTAL) SS Requiring Beds)

LINE 9 — ORTHOPEDIC (SO)____HYPHEN_____TOTAL_____(Number of Litter (After SO), Ambulatory (After HYPHEN), and All (After TOTAL) SO Requiring Beds)

LINE 10 — BURN (SB)__________HYPHEN_____TOTAL_____(Number of Litter (After SB), Ambulatory (After HYPHEN), and All (After TOTAL) SB Requiring Beds)

LINE 11 — SPINAL CORD (SC)___HYPHEN_____TOTAL_____(Number of Litter (After SC), Ambulatory (After HYPHEN), and All (After TOTAL) SC Requiring Beds)

LINE 12 — OB/GYN (SG)________HYPHEN_____TOTAL_____(Number of Litter (After SG), Ambulatory (After HYPHEN), and All (After TOTAL) SG Requiring Beds)

LINE 13 — PEDIATRIC (MC)_____HYPHEN_____TOTAL_____(Number of Litter (After MC), Ambulatory (After HYPHEN), and All (After TOTAL) MC Requiring Beds)

LINE 14 — NEURO (SSN)________HYPHEN_____TOTAL_____(Number of Litter (After SSN), Ambulatory (After HYPHEN), and All (After TOTAL) SSN Requiring Beds)

LINE 15 — MAXILLO (SSM)_____HYPHEN_____TOTAL_____(Number of Litter (After SSM), Ambulatory (After HYPHEN), and All (After TOTAL) SSM Requiring Beds)

LINE 16 — OPHTHAL (SSO)_____HYPHEN_____TOTAL_____(Number of Litter (After SSO), Ambulatory (After HYPHEN), and All (After TOTAL) SSO Requiring Beds)

LINE 17 — THORACIC (SSC)_____HYPHEN_____TOTAL_____(Number of Litter (After SSC), Ambulatory (After HYPHEN), and All (After TOTAL) SSC Requiring Beds)

**Use lines 14 through 17 to report the number of patients requiring beds in selected surgical sub-specialties. Include these numbers in line 8. Assign sequential line numbers to succeeding iterations; for example, first iteration 14 through 16; second iteration 14a through 17a; third iteration 14b through 17b; and so on.

LINE 18 — CATEGORY__________________________________(Number of Special Category Patients (Other Than Active Duty US Armed Forces) Assigned Beds at Destination MTE by Medical Specialty Category (EXAMPLE: 2 French Nationals))

LINE 19 — PICKUP_____________________________________(Pickup Location in UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator)

LINE 20 — ONLOAD___________HYPHEN_____TOTAL_____(Number of Litter (After ONLOAD), Ambulatory (After HYPHEN), and All (After TOTAL) Patients to be Picked Up)

LINE 21 — EQUIPMENT_________________________________(Special Medical Equipment Required)

LINE 22 — NARRATIVE_________________________________(Free Text for Additional Information Required for Clarification of Report

**Repeat lines 19-22 as a group to identify patient pickup location and time available for movement when involving more than one location and time. Assign sequential line numbers to succeeding iterations; for example, first iteration 19 through 21; second iteration 19a through 21a; third iteration 19b through 21b; and so on.

**Repeat lines 3 through 22 as a group for each MTE requesting beds when reporting for more than one MTE. Assign sequential line numbers to succeeding iterations; for example, first iteration 2 through 22; second iteration 2a through 22a; third iteration 2b through 22b; and so on.

LINE 23 — AUTHENTICATION___________________________(Report Authentication)


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