Call Review Entry Form

Please fill out the following questions regarding your call that you would like us to review. DO NOT provide any Protected Patient Health Information, this is a HIPAA violation and will not be accepted under any circumstance. If you have any questions about the survey or need to provide further information about your call please email info@medicmaterials.com

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* 1. Describe the EMS System this call occurred in. Was it Urban, Suburban, Rural? How many providers are on the call and their certification status? (E.G 1 Medic in Flycar, with 2 EMT BLS Transporting Ambulance)

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* 2. Describe the initial dispatch information given to the responding EMS providers.

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* 3. Describe the Scene Size Up information. Who was on scene, What did the scene look like, how did the patient present? From there please describe What are your initial physical findings on scene? Initial vital signs obtained?

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* 4. What is the history of present illness? What lead to the ems system being activated? Please be as specific as possible. What are the patients' pertinent medical history, medications and allergies?

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* 5. What interventions are performed/attempted on scene prior to extrication to the transporting unit? Did these interventions improve or decline the patient condition? How was the patient extricated to the transporting unit? How much time between initial ems contact and within the transporting unit?

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* 6. What physical findings are found in the secondary physical assessment? Are there changes to the patient condition/presentation? What interventions are performed/attempted while transporting to the hospital? Who are performing these assessments and interventions? Are there any improvements or declines in the patient condition? Be as specific as you can.

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* 7. What are the trends for vital signs through the call? Blood Pressure, Heart Rate, Respiratory Rate, Blood Glucose, Spo2, ETCO2, GCS.

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* 8. (No names) What are the hospitals capabilities in this area? Are they a community hospital with limited capability, Trauma Centers, Stroke Centers, Cardiac Cath Centers. Which was the hospital you transported to and how far away was it in minutes from where you transported? Did you receive a patient update or diagnosis from the receiving hospital? If yes please explain.

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* 9. Was there an unusual circumstance or situation that occurred on this call you believe is pertinent to discuss during the call review? Please explain if yes? 

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* 10. Please provide a valid email, in case we need to contact you for further questioning or clarification of your call entry. 

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