* 1. Date:

* 2. Name of Entity:

* 3. Person Completing Report:

* 4. Performance Improvement Criteria / Indicators
Number of times scene time > 20 minutes for an injury-related call this quarter.

* 5. Number of trauma related pediatric resuscitations.

* 6. Number of patients that met the RAC-D definition of “Major Trauma” that were transported to hospitals outside of RAC-D this quarter.

* 7. Number of trauma-related patients pronounced dead on scene this quarter.

* 8. Number of non-preventable trauma deaths this quarter.

* 9. Number of potentially preventable trauma deaths this quarter.

* 10. Number of preventable trauma deaths this quarter.

* 11. Number of times Air Medical Services requested but unable to respond this quarter.

* 12. Specific Occurrence Report
Age:

* 14. Chart Identification #:

* 15. Mechanism of Injury:

* 16. Identified injuries and pertinent information:

* 17. Patient Outcome:

* 18. Provider Discussion:

* 19. Contributing Factors

T