Patient Care Report- Quality Review Checklist ALS
Truck Designation ______
Attendants ___________ ___________
Date of call ________________
Run # _______________
Primary Complaint:
Airway
Allergic reaction/ Anaphylaxis
Asthma
Altered Mental Status
Cardiac dysrhythmia
Chest pain
CVA
Diabetic
GI Disorder
HTN
Overdose
OB/Gyne
Pediatric (all)
Seizures
Trauma
Any answer in column (B) requires review of the patient care report by committee as a minimum
Indicators
Patient info complete?
All Mandatory fields complete?
Patient Refusal?
Treat and release?
Triage to BLS Appropriate?
Response times appropriate?
Scene time appropriate?
A
Y
Y
N
N
Y
Y
Y
B
N
N
Y
Y
N
N
N
Initial Vital Signs?
Vital Signs after intervention/procedure?
Vital signs repeated as appropriate?
Physical exam appropriate for complaint?
Patient Medications/ Allergies listed?
Patient History listed?
History appropriately detailed?
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Proper Equipment used (ECG, 12lead, Hbg oximetry)
Standing Orders followed as indicated by pt condition?
Logical progression of Rx?
Controlled Substance used?
If so was weight, dose, allergies , MD orders
documented appropriately?
Cardiac arrest?
Dead on scene?
DNR/Comfort Care in place?
DNR Comfort Care number documented?
Patient condition deteriorate enroute?
Transport according to point of entry?
Online Medical Control as required?
Y
Y
Y
N
Y
N
N
N
Y
N
N
N
Y
Y
N
Y
N
Y
Y
N
N
Y
N
Y
Advanced Airway utilized?
If unsuccessful was rescue airway utilized?
Acceptable methods of confirmation used?
Placement reconfirmed
More than (3) attempts @ ETT
All attempts @ providing an advanced airway ( ETT or
Combitube)unsuccessful?
N
N
Y
Y
N
N
Y
Y
N
N
Y
Y
IV Size appropriate?
IV attempts > 3?
Y
N
N
Y
Pediatric call?
N
N
Y
Y
Overall documentation poor/lacking info? Please specify
Comments
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
QA/QI committee comments:
Clinical Director comment:
Medical Directors comment:
Final Resolution: