EMT Upgrade Audit Form

Pittsburgh EMS EMT Upgrade Audit Form Confidential: This document is part of the City of Pittsburgh, Bureau of EMS –University of Pittsburgh Medical Center Quality Improvement process. Incident #

E EMT Unit Dispatch Date ALS Unit

Narrative Comment History  Excellent  Satisfactory  Limited -Chief complaint, Hx present illness, Past Hx, Meds, Allergies Physical Exam  Excellent  Satisfactory  Limited -Vital signs, focused physical exam, repeat vitals after change in status Treatment  Excellent  Satisfactory  Limited -Timeliness of actions, documentation of results of treatment Trip sheet Overview  Excellent  Satisfactory  Limited -Organization, content, readability Upgrade/Downgrade ALS Crew met EMTs Did BLS request ALS upgrade?  Yes  No  On scene  Rendezvous Did ALS request BLS downgrade?  Yes  No Transport  BLS unit  ALS unit  BLS w/ ALS crew  ALS w/ BLS crew Times minutes Reason for upgrade -Dispatch to First unit arrival......  Altered LOC  Resp Distress -Arrival to time of request for assistance.….  Altered VS  Pain Control -Time of request until Second unit Arrival….  Chest pain  Other: -Second unit Arrival to depart scene...... -Depart scene to arrive at facility.....……… ALS Procedures performed  None  IV  Monitor  Intubation  Defib  Medication admin ______ Other______ Glucose Check ______1. Did the EMTs package the patient prior to ALS arrival?  Yes  No 2. Was the wait time for ALS > transport time?  Yes  No

Additional comments

Reviewer Date reviewed EMT Crew

Reviewer requests feedback if this box is  Date feedback was received / /