HomeMy WebLinkAbout106.008 - EMS Quality Improvement Form (EMS-1A)Effective Date: December 2018 Kevin Reynolds, Captain
Current Revision Date: 07/13/2022 Section 106.008
Next Revision (2) Date: 07/13/2024 Page 1 of 4
100 Administrative Manual
SECTION 106.008 EMS QUALITY IMPROVEMENT FORM (EMS-1A)
PURPOSE
Provide feedback involving unusual occurrences within the Emergency Medical
Services (EMS) System.
APPLICATION
The EMS-1A form may be completed online and submitted to the EMS Coordinator
whenever a Fresno Fire Department (FFD or Department) member notes an issue
needing correction regarding any EMT or Paramedic’s performance.
OPERATIONAL POLICY
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OPERATIONAL GUIDELINE
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PROCESS
Complete the EMS-01A form online and email it to the EMS coordinator.
INFORMATION
For more information, access the following link:
http://www.co.fresno.ca.us/home/-showdocument?id=13365
DEFINITIONS
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Fresno City Fire Department
Effective Date: December 2018 Kevin Reynolds, Captain
Current Revision Date: 07/13/2022 Section 106.008
Next Revision (2) Date: 07/13/2024 Page 2 of 4
CROSS-REFERENCES
No cross references recognized.
Effective Date: December 2018 Kevin Reynolds, Captain
Current Revision Date: 07/13/2022 Section 106.008
Next Revision (2) Date: 07/13/2024 Page 3 of 4
CENTRAL 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)
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Incident Logistics
Call Location: ______________________________________________________________________ EMS Disp#: ______________
Date: _________________________________ Time: __________________________ Location: On Scene Enroute
At Hospital Other
Patient Name: _______________________________________ Med. Record # or DOB: __________________________________
PCR/BHRR# (Attach Copy): ______________________________
Personnel Involved Agency Discussed with Individual
_________________________________________________________________ Yes No
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Primary Tracking
Date & time On-Duty Supervisor/PLN/PLO Notified: ______________________________________________________
Name & Title of Individual Contacted: __________________________________________________________________
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Author Information
Signature: __________________________________________ Date: _________________________________
Print Name: ________________________________________ Cert #: ________________________________
OFFICIAL USE ONLY
CQI # __________________________
DATE RCVD: ___________________
Emergent Non-Emergent
Effective Date: December 2018 Kevin Reynolds, Captain
Current Revision Date: 07/13/2022 Section 106.008
Next Revision (2) Date: 07/13/2024 Page 4 of 4
Agency/Facility: ____________________________________ Date Submitted to PLO/PLN: ______________
Documentation Area
Issue: (Please state in one or two sentences)
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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)