HomeMy WebLinkAboutSFRF Review ChecklistBEAUMONT FIRE/RESCUE
QUALITY ASSURANCE PROGRAM
STANDARD FIREHOUSE REPORT FORM (SFRF) REVIEW CHECK LIST
Check List Criteria must be utilized when reviewing a SHRF using this form.
[1] Run #:
[2] Unit #:
[3] DATE/TIME OF CALL:
[4] A1C:
[s] EMT #:
[6] EMT:
EMT#:
EMT:
EMT#:
EMT:
EMT#:
EMT:
EMT#:
[7] 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:
[s] Priority:
[9] Nature of Call:
po] Response Time:
[11] On -Scene
Time:
[12] Extenuating Circumstances: [ ] Yes [ ] No
[13] If Yes, explain:
[14] Age of Patient:
[151 Gender: [ ] F [
] M [16] Patient Care
Level [ ] BLS [ ] Intermediate [ ] Paramedic
[17] Pt. Transported:
[ ] Yes
[ ] No If No, explain:
A. DOCUMENTATION S= Satisfactory I= Improvement Needed A = Absent NA= Not Applicable
S 1 A NA
p8] Run Info. Date,Unit
[19] Pt. Info. (Name, Address, Age, IM)
[20] Crew/Times
[21] Reason for Call/ Clin. Improv.
[22] Allergies Noted
[23] Medications - Current
[24] Past Medical History
[25] History of Present Illness
[26] Physical Exam Findings
[36] Comments:
S 1 A NA
[27] 'Treatment
[28] Outcome/Results of Treat.
[29] Observation Continued
[so] Glasgow/Trauma Scores
[31] Vital Signs (Repeated?)
[32] Procedures/Medications
[33] Signatures
[34] Protocol followed
[35] Other:
B. CLINICAL AUDIT A= Acceptable/Appropriate I= Improvement Needed U= Unacceptable/Inappropriate
RFI = Requires Further Investigation NA= Not Applicable
A I U RFI NA
[37] Response Time
[38] Scene Time
[39] Dispatch ofBLS/ALS
[40] Utilization of BLS/ALS
[41] Assessment
[42] Trauma Team Activation
[49] Comments:
A I U RFI NA
[43] Treatment/Procedures
[44] Policy Adherence
[45] Overall Documentation
[46] Overall Performance
[47] Cardiac Alert
[48] Other:
C. SHILLS LOG No credit will be given for any skill that was not clinically indicated according to Region V Treatment
Protocols. Check the "NI" (Not Indicated) column if this was the case.
Procedure EMT Performing Skill # Attempts # Successes NI
[5o] Glucometer
[51] 1V
[52] Rhythm Interpretation
[53] EKG (attach copy)
[54] ETT
[55] External Pacing
[56] Defibrillation
[57] Medication Admin.
Med 1:
Med 2:
Med 3:
Med 4:
[58]
[59]
[60]
[61] Other:
[62] Comments:
[63] D. NOTES
[64] E. ACTION TAKEN BY SERVICE QA COORDINATOR [ ] notification only
[65] F. ACTION TAKEN BY QA COMMITTEE [ ] notification only
[66] G. ACTION TAKEN BY EMS MEDICAL DIRECTOR [ ] notification only
[ ] see attached pages
[ ] see attached pages
[ ] see attached pages
[ ] see attached pages
[67] H. FOLLOW-UP REQUESTED [ ] notification only [ ] see attached pages
[68] L Training Division Actions [ ] none [ ] see attached pages