Date of this Audit*

Employee*

Arel Baker Berube Brady Brown Bullock Campbell Cole DeMarco Doherty Dubowick Dunn Fisher Fournier Hildebrandt Kurgan Lundergan McPherson Merrill Moltenbrey Nault Robertson Savard Sliver Specian Tangney Taylor Zins Test Employee

Officer*

L1 L2 L3 L4

Run #*

Date of Incident*

NOTE MISSING OR INCORRECT INFORMATION BELOW

Incident Information

Run # Incident Date Times Dispatch Reason

Responding Unit Mileage Incident Information

Call Information

Destination Name

Demographic

Pt. Name Gender DOB SS# Pt. Address

Phone # Medical History Pt. Drug Allergies Medications

Condition

Pt. Status Chief Complaint Duration of C/C Secondary Complaint

Duration of 2nd C/C Primary Symptoms Other Symptoms

Trauma/Arrest

Possible Injury Pre-Ambulance AED

Return of Circulation

Physical Assessment

Medical Assessment Injury Assessment

Burn Assessment

Vitals / Treatments

Protocols Medications Procedure

Vital Signs EKG

Narrative

Condition of Pt. at Destination Primary Impression Vehicular Info

ED MD Narrative

Billing

Insurance Information CMS Service Level

Next of Kin

Signatures

Pt. Signature Parent / Guardian Technician

Physician Receiving Agent

Review for CQI requested

Comments (5 rows / 500 Characters)