General PCR QA Form 

Fill this form for general quality assessment of PCRs

Agency *
Patient Age *
Quality Assessment
Mechanism/Chief Complaint clearly explained
Pertinent medical history obtained
Physical exam appropriate
3-lead obtained, interpretation charted
12-lead obtained, interpretation charted
Choose Yes if this is a BLS crew & they obtained a 12-lead for the hospital/ALS provider to interpret.
2 sets of vital signs minimum
Choose N/A if 1 set obtained but care turned over to another unit that will be obtaining another set on the same patient.
Patent airway/proper O₂ therapy
Does not require an intervention if the patient is maintaining their own airway and has adequate SPO2/ETCO2
Vascular access obtained
Appropriate protocols or orders utilized
Properly medicated
Select No for inappropriate medications/dosages given or a medication witheld that should have been given.
Appropriate spinal motion restriction
See SAEMS Spinal Clearance SO & Spinal Immobilization Protocol
Base Hospital review needed
No Protected Health Information