*PLEASE SEND INFORMATION WHEN DISCOVERED THROUGHOUT THE QUARTER SO REVIEW CAN BE STARTED PRIOR TO RAC MEETING*
SEND TO: thamilton@fishercountyhospital.com or denid@rpmh.net

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1. Reporting Quarter

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2. Name of Entity:

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3. Person Completing Report:

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4. Performance Improvement Criteria / Indicators
Number of occurrences scene time greater than 20 minutes this quarter.

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5. Why was the scene time > than 20 minutes?

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6. Performance Improvement Criteria / Indicators
Number of occurrences greater than 30 minutes from dispatch to arrival on scene this quarter.

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7. Why was the scene time > than 30 minutes?

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8. Number of occurrences lift off time > 10 minutes from time mission accepted.

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9. Explanation of above:

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10. Number of missed flights this quarter.

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11. Why were there missed flights this quarter?

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12. For each patient above who was transferred out of TSA-D what was the determining diagnosis or factor that led to transfer out of TSA-D?

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13. NUMBER OF STROKE PATIENTS TRANSPORTED BY AIR MED TO A RAC-D FACILITY FROM SCENE?

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14. IF NOT WITHIN RAC-D, WHY AND WHERE?

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15. NUMBER OF STEMI PATIENTS TRANSPORTED BY AIR MED TO A RAC-D FACILITY FROM SCENE?

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16. IF NOT WITHIN RAC-D, WHY AND WHERE?

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17. **LEAVE THIS AREA BLANK IF YOU ARE NOT NEEDING THE PI COMMITTEE TO REVIEW A CHART**
Specific Occurrence Report
Age:

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18. Gender:

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19. No Names - Chart Identification #:

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20. Mechanism of Injury:

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21. Identified injuries and pertinent information:

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22. Patient Outcome:

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23. Reason for PI Committee Review

*PLEASE SEND INFORMATION WHEN DISCOVERED THROUGHOUT THE QUARTER SO REVIEW CAN BE STARTED PRIOR TO RAC MEETING*
SEND TO: thamilton@fishercountyhospital.com or denid@rpmh.net

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