Roaring Fork Fire Rescue Authority EMS QM Program Case Review Rating (required) Exceptional Care Insufficient Documentation No Adverse Outcome Major Adverse Outcome Appropriate Care Poor Communication Minor Adverse Outcome Systems Issue Identified Incident Number (required) Indication for Review (required) Death Non-compliance with guidline /protocol Charting deficiency Full Trauma Activation Criteria Met Trauma Under-Activation Abnormal EKG Transmissions Stroke Symptoms All Waivered ACT Hospital or Agency Request for Review Provider or Authority Request Patient DOB (required) Station Number (required) Crew Involved (required) Date of Incident (required) Call Request Dx (required) Emergent Non-Emergent Transport Dx (required) Emergent Non-Emergent No Transport Dispatched (required) Arrived (required) Transport (required) Arrival (required) Destination (required) AVH VVH Refusal No Transport Scene Address (required) City (required) State (required) Zip Code (required) Patient chief complaint and history documented appropriately? (required) Yes No Details Patient Assessment and impressions documented appropriately? (required) Yes No Details Cardiac arrest documented appropriately? (required) Yes No Details Vital signs documented and ECG uploaded appropriately? (required) Yes No Details Interventions prioritized appropriately and administered per protocol? (required) Yes No Details Trauma level identifited appropriately (required) Yes No N/A Details Narrative includes adequte information? (required) Yes No Details Provider Issue System Issue Loop Closure (required) Officer Reviewing ePCR First and Last Name (required) Email (required) Your Signature (required) Confirm e-Signature Review Electronic Records and Signatures Policy (required)Read our Electronic Record and Signature Disclosure I agree to use electronic records and signatures There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
