Cardiac Arrest QA Form 

Fill this form for calls where resuscitative measures are started/continued by EMS.

Demographics
Agency *
Patient Age *
Dispatch Time
Dispatch Time
On Scene Time
On Scene Time
Transport Time (if applicable)
Transport Time (if applicable)
Transfer of Care/Time of Death
Transfer of Care/Time of Death
Quality Assessment
Prior Aid/CPR?
No names, just relationship (i.e. son, family, bystander, other agency, etc.)
Witnessed arrest?
Return of spontaneous circulation achieved by EMS?
Was patient transported before return of circulation?
If patient is in Refractory V-fib/tach or has PEA with ETCO2 > 20 at time of transport, select "No"
This includes any prior to EMS arrival
Time of 1st defibrillation
Time of 1st defibrillation
any defibrillation by any agency/individual
Was IV/IO access established?
Documentation of patent airway/proper O₂ therapy?
Was Cardiac Arrest Standing Order followed correctly?
Base Hospital review needed
No Protected Health Information