HomeMy WebLinkAboutQA-AI Report Review ChecklistBEAUMONT FIRE -RESCUE - QUALITY ASSURANCE PROGRAM
REPORT REVIEW CHECK LIST
p] Incident #: [z] Unit: [3] DATE/TIME OF CALL:
[4] Dispatcher (if known): [s] EMT AIC (if known): EMT#:
[6] Reviewed by: [ ] MASG QA Coordinator Name: Date:
[ ] MASG QA Chair Name: Date:
[ ] Other Name: Date:
[ ] Other Name: Date:
[ ] Other Name: Date:
[ ] Other Name: Date:
[ ] Other Name: Date:
[7] Priority: [s] Nature of Call:
[9] Dispatched As: pot Dispatch Time:
p i] Extenuating Circumstances: [ ] Yes [ ] No [12] If Yes, explain:
[13] Age of Patient: [ia] Gender: [ ] F [ ] M [is] Patient Care Level [ ] BLS [ ] Intermediate [ ] Paramedic
A. CLINICAL AUDIT A= Acceptable/Appropriate I= Improvement Needed U= Unacceptable/Inappropriate
RFI = Requires Further Investigation NA= Not Applicable
A 1 U RFI NA
[16] Patch Clear and Audible
[17] Priority
p s] EMT Name, Level
p9] Pt. Description
[zo] Chief Complaint
[211 Description
[zs] B. NOTES
[29] C. ACTION TAKEN BY DISPATCH.
[so] D. ACTION TAKEN BY QA COMMITTEE
A 1 U RFI NA
[22] Treatment Provided
[23] Orders Requested
[z4] ETA
[zs] Overall Performance
[z6] Other:
[z7] Other:_
[31] E. ACTION TAKEN BY EMS MEDICAL DIRECTOR
[32] F. FOLLOW-UP REQUESTED
[ ] see attached pages
[ ] notification only [ ] see attached pages
[ ] notification only [ ] see attached pages
[ ] notification only [ ] see attached pages
[ ] none [ ] see attached pages
[33] G. FOLLOW-UP REQUESTED [ ] none [ ] see attached pages