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Home My WebLink AboutEMS-01A - EMS Quality Improvement ReportCENTRAL CALIFORNIA EMERGENCY MEDICAL SERVICES COUNTY INVOLVED: FRESNO KINGS MADERA TULARE OTHER ______________________________________ CONFIDENTIAL (In accordance with California Civil Code Section 56, et seq, California Evidence Code Section 1040 and Section 1157, et seq, and California Code of Regulations, Title 22, Division 9) Quality Improvement Report (Information for Attorneys representing the Central California EMS Agency) __________________________________________________________________________________________________ Incident Logistics EMS Disp#:Call Location: ______________________________________________________________________ ______________ Location: Time: Date: _________________________________ __________________________ On Scene Enroute At Hospital Other Med. Record # or DOB: Patient Name: _______________________________________ __________________________________ PCR/BHRR# (Attach Copy): ______________________________ Personnel Involved Agency Discussed with Individual Yes No _________________________________________________________________ _________________________________________________________________ Yes No _________________________________________________________________ Yes No _________________________________________________________________ Yes No _________________________________________________________________ Yes No _________________________________________________________________ Yes No _________________________________________________________________ Yes No __________________________________________________________________________________________________ Primary Tracking Date & time On-Duty Supervisor/PLN/PLO Notified: ______________________________________________________ Name & Title of Individual Contacted: __________________________________________________________________ __________________________________________________________________________________________________ Author Information Date: Signature: __________________________________________ _________________________________ Cert #: Print Name: ________________________________________ ________________________________ Date Submitted to PLO/PLN: Agency/Facility: ____________________________________ ______________ OFFICIAL USE ONLY CQI # __________________________ DATE RCVD: ___________________ Emergent Non-Emergent Documentation Area Issue: (Please state in one or two sentences) ____ ____ ____________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Account of Incident: Initial: 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__________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __ __ __ __ __ __ __ __ __ _ __ _ _ __ __ __ __ __ __ __ __ ________________________________________________________________________________________________________ Proposed Resolution: (Author Must Complete) Initial: ________ ____ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 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________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ _____________________________________________________________________________________________________ _______ ____ ___ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ _____________________________________________________________________________________________________ Initial: ________ (Final completed form will be forwarded to County Counsel from the EMS Agency)