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* 1. Date:

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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 times scene time > 20 minutes for an injury-related call this quarter.

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* 5. Performance Improvement Criteria / Indicators
Number of times >30 minutes from dispatch time to scene time for an injury-related call this quarter.

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* 6. Number of trauma related pediatric resuscitations.

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

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

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

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

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* 11. Number of preventable trauma deaths this quarter.

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

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* 13. Specific Occurrence Report
Age:

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* 15. Chart Identification #:

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* 16. Mechanism of Injury:

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* 17. Identified injuries and pertinent information:

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* 18. Patient Outcome:

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* 19. Provider Discussion:

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* 20. Contributing Factors

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