Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Daily Fluid Check

  • Checked?

  • Oil

  • Antifreeze

  • Transmission Fluid

  • Break Fluid

  • Windshield Fluid

  • Steering Fluid

Tire Pressures

  • Checked?

  • Drivers Side Front

  • PSI

  • Passenger Front

  • PSI

  • Drivers Rear Tire

  • PSI

  • Drivers Inner Tire Pressure

  • PSI

  • Passenger Rear Tire

  • PSI

  • Passenger Inner Tire Pressure

  • PSI

  • Treads OK?

Compartment A-1 6 Emesis Basins 1 Current OSHA Book 1 Jane Biohazard Book 6 Bottles NSS 1 ANSI Vest 2 PPE Kits 1 NIOSH Book 1 Box Particle Masks 6 Bottles Sterile Water

  • Tag #'s

  • Add media

Compartment A-2 4 Adult NRB 4 Adult Nasal Cannula 4 Nebulizers 1 Pocket Mask 2 Adult BVM 1 Spare Suction Canister w/tubing 1 Each French 6,8,10,12,14,16,18 Catheters 6 Oral Airways 2 Adult Simple 2 Adult Trach Masks 2 Oxygen Tubing 1 Humidifier Kit 4 Yankauer 6 Surgilube 5 Nasal Airways

  • Tag #'s

  • Add media

Shelf A-3 2 - Blankets 2 - Sheets

  • Linen Stocked?

  • Add media

Compartment A-4 Pedi Bag Trauma Bag 1 CPAP Unit 1 CPAP Spare Circuit

  • Pedi Bag Tag #

  • Trauma Bag Tag #

  • C-PAP Tag #

  • C-PAP Spare Circuit

  • Add media

Compartment A-5 6 -Pillow Cases 6 - Sheets 6 - Towels 6 - Blankets

  • Tag #'s

  • Add media

Compartment A-6 5 Hot Packs 10 Triangle Bandages 3 Burn Sheets 10 Combine Dressings 1 Box 4x4's 1 Roll Hypo Tape 1 Box Tissues 5 Brown Paper Bags 4 Small Kling 1 Bulb Syringe 10 Non Adhering Dressings 2 OB Kits 3 Oral Glucose 1 Crash Shears 1 Foil Baby Bunting 5 Cold Packs 1 SAM Splint 5 Trauma Dressings 1 Box 2x2's 4 Rolls of Various Tape 10 Drinking Cups 1 Thermometer w Covers 1 Box Band Aids 4 Large Kling 1 Ring Cutter 1 Razor 1 Roll Sterile Aluminum Foil 1 Pen Light 1 Bandage Scissors

  • Tag #'s

  • Add media

Interior Shelf Area

  • Main Oxygen PSI

  • Suction Working

  • Suction Canister w/tubing

  • 1 - Yankauer

  • ALS Protocol Book

  • Add media

Compartment A-7

  • 1 - Box Non-Latex Gloves

  • 1 Box Large Non-Latex Gloves

  • Add media

Compartment A-8

  • Tag #

  • Spare ANSI Vest

  • Add media

Compartment A 9 2 - Boxes Small Non-Latex Gloves 1 - IV Kit 3 - Each IV Caths 14,16,18,20,22,24 5 - OP Sites 1 - Bottle Baby ASA 3 - Flushes 2 - IV Start Kits 1 - 500 NSS 1 - 20 Drip 1 - Roll Tape 1 - Nitro Spray 2 - Extension Sets 5 - Alcohol Wipes

  • 2 Boxes Small Non-Latex Gloves

  • 1 Bottle Baby ASA

  • Baby ASA Expiration Date

  • 1 Bottle Nitro Spray

  • Nitro Spray Expiration Date

  • 1 IV Kit

  • Add media

Compartment A-10 1 - Can Lysol 10+ Biohazard Bags 1 - Container Disinfectant Wipes 1 - Purell

  • Tag #

  • Add media

Under Airway Seat

  • 1 - Bed Pan

  • 1 - Urinal

  • Add media

Interior

  • 2 - Full Oxygen Tanks (one w regulator)

  • 2 - Flashlights

  • 1 - Fire Extinguisher

  • 1 - Long Board w Straps

  • 1 - Cooler with Saline

  • Drug Box Tag #

  • Add media

Cockpit

  • Vehicle Inspection Valid

  • Mileage Reading

  • Add media

  • Fuel Level

  • Insurance/Owners Cards

  • Garage Door Opener

  • Map Book

  • GPS Unit

  • Personal CO Detector

  • Accident Pack

  • Non-Latex Gloves Sm,Med,Large,X-Large

  • Nextel with Charger in Cab

  • Tire Pressure Gauge

  • 2 PFD's

  • MCI Kit Behind Passenger Seat

  • ALL EMERGENCY LIGHTS WORKING

  • Front Heat and AC Working?

  • Rear Vent Working?

  • Gas Cards Present?

  • UPMC East Card Present

  • Entry Keys/The Oaks/152 Royal Oak Drive?

  • Morning DECON Performed

  • Vehicle Cleaned

  • Interior Rear Lights Working?

  • Any new damage to vehicle

  • Drivers Sider Door ANSI Class II Vest

  • Passenger Side Door ANSI Class II Vest

  • Exterior Vehicle Lights Working? (Head lights,turn signals, etc)

  • Is Cockpit clean?

Clip Board

  • 15 Patient Forms

  • 5 DOA Forms

  • 5 Refusal Forms

  • 2 Pens

  • 2 White Oak EMS Quick Registration Forms

Monitor Top Pocket - 4 misc cuff sizes (infant,pedi,small,large) Left Pocket - Pulse Ox Cable, Leads, Adult Cuff Right Pocket - Therapy Cables, Pedi Combo Pads, 12 Pedi Electrodes, Roll Paper, 2 ET CO2 Circuits, 1 Nasal ET CO2 Circuit Rear Pocket - 2 Adult Quick Combo Pads, Razor, 12 lead cables, 6 packages adult electrodes, 1 Blue Tooth

  • Battery #1

  • Battery #2

  • Self Test Passed

House Bag/Oxygen/Portable Suction Cabinet

  • Portable Suction Working

  • Spare Battery

  • Canister with Tubing

  • 2 Yankauer's

  • 8 French

  • 10 French

  • 12 French

  • House Bag Top Tag #

  • Front Tag #

  • Right Tag #

  • Left Tag #

  • Back Tag #

  • Red Seal in Tact

Oxygen Bag 1 NRB 1 Nasal Cannula 1 Nebulizer 1 Glucometer w Supplies 2 Albuterol's 2 Atrovent

  • Oxygen PSI

  • Add media

  • Pulse Ox Present and Working

  • Stethoscope

  • BP Cuff

  • Personal CO Detector Present & Working

  • Any items missing?

  • Missing Items

  • DRUG BOX TAG #

  • Add media

Under the Bench Seat

  • 1 - Hare Traction Splint

  • 1 - Pedi Hare Traction Splint

  • 1 - Pedi Immobilizer

  • 1 Spare Pillow

  • 1 Full Arm Splint

  • Half Arm Splint

  • Foot/Ankle Splint

  • Full Leg Splint

  • Half Leg Splint

  • Hand/Wrist Splint

  • 1 Full E Cylinder with CPAP Connection

  • PSI

  • 1 - Case Bottled Water

  • 1 Bottle of Cleaning Wipes

Exterior Rear Passenger Side Compartment

  • Tool Box Tag #

  • Add media

  • Smart Triage/Red Duffle Bag Tag #

  • Add media

  • 1 Chemical Approach Duffle Kit

  • 1 Case Bottled Water

Exterior Front Drivers Side Compartment

  • 6 Padded Board Splints (2 of each size)

  • 1 Reeves Stretcher

  • 1 - KED

Exterior Middle Drivers Side Compartment

  • 2 Helmets

  • 2 sets of turn out gear

Exterior Rear Drivers Side Compartment

  • 1 Long Board with straps

  • 1 - Stairchair

  • 1 Scoop Stretcher

  • 2 sets of CID's with straps

  • 1 Collar Bag containing 6 collars, 1 of each size

  • 5 - 9ft straps on door

Collars on Door

  • Infant

  • Pedi

  • No Neck

  • Short

  • Regular

  • Tall

ALS Drawer

  • Monitor Battery

  • Monitor Paper

  • MAD Device

  • 1000 NSS

  • 20 Drip

  • 2 - Flushes

  • 2 - IV Caps

  • D-50

  • D-50 Expiration Date

  • Alcohol Wipes

  • 2 - Nebulizers

  • 2 - NRB

  • 2 - Nasals

IV Caths

  • 2 - 20ga

  • 2 - 18ga

  • Lancets

  • Arm Board

  • Electrodes

  • Tape

  • OpSites

  • 4 - Albuterol

  • IV Start Kit

  • IV Extension Set

  • 1 - Cold Pack

MORNING DECON

  • Morning DECON Performed

  • Truck Clean

  • New Damage

  • Exterior Lights Working

Temperatures

  • Drug Cabinet Degrees

  • Cooler Degrees

  • Rear Patient Area Degrees

  • Comments/Deficiencies/Suggestions

  • Crew Member #1

  • Crew Member #2

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