Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Daily Fluid Check
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Checked?
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Oil
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Antifreeze
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Transmission Fluid
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Break Fluid
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Windshield Fluid
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Steering Fluid
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Daily Fluid Check
Tire Pressures
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Checked?
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Drivers Side Front
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PSI
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Add media
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Passenger Front
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PSI
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Add media
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Passenger Rear Outer Tire
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PSI
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Add media
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Passenger Rear Inner Tire
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PSI
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Add media
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Drivers Rear Outer Tire
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PSI
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Add media
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Drivers Rear Inner Tire
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PSI
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Add media
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Treads OK?
Compartment A-1 6 Emesis Basins 6 Bottles NSS 1 ANSI Vest 2 PPE Kits 1 Box Particle Masks 6 Bottles Sterile Water 3 Bags 1000 mL nSS
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Tag #
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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
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Tag #
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Add media
Compartment A-3 1 Pedi Bag
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Tag #
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Add media
Compartment A-4 Region 13 MCI Kit 1 NIOSH Book 1 Jane Biohazard Book 1 Current OSHA Book 1 ALS/BLS Protocol Book
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MCI Bag Tag #
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Add media
Compartment A-5 1 CPAP Unit 1 CPAP Spare Circuit
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Tag #
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Add media
IV Drawer 2 each IV Caths 14,16,18,20,22,24 5 Opsites 1 Bottle Baby Aspirin 2 IV Caps 2 IV Start Kits 1 MAD Device 1 1,000 NSS 1 20 Drip 1 Roll Tape 1 Nitro Spray 2 Flushes 5 Alcohol Wipes 5 2x2's 2 Extension Sets
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1 Bottle Baby ASA
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Baby ASA Expiration Date
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1 Bottle Nitro Spray
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Nitro Spray Expiration Date
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Missing Items -
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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
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Tag #'s
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Add media
Compartment A-7 1 LP 15 Monitor
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Present and Functioning
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Self Test Passed?
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Add media
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
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Battery #1
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Battery #2
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Any missing items?
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Missing Monitor Items
Compartment A-8 1 Spare Monitor Battery 5- 9" Straps 1 Spare Roll Monitor Paper
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Tag #'s
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Add media
Compartment A 9 6 Pillow Cases 6 Sheets 6 Towels 6 Blankets
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Tag #'s
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Add media
Compartment A-10 Spare Linen 4 Towels 4 Blankets 4 Sheets 4 Pillow Cases
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Linen Stocked?
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Add media
Compartment A-11 1 Can Lysol 10+ Biohazard Bags 1 Container Disinfectant Wipes 1 Purrell
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Tag #'s
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Add media
Compartment A-12 1 Box Small Non Latex Gloves 1 Box Medium Non Latex Gloves 1 Box Large Non Latex Gloves
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Gloves Stocked?
Under Airway Seat 1 Bed Pan 1 Urinal
Cockpit
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Vehicle Inspection Valid
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Mileage Reading
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Add media
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Fuel Level
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Insurance/Owners Cards
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Garage Door Opener
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Map Book
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GPS Unit
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EZ-Pass Present
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Personal CO Detector
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Accident Pack
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Non-Latex Gloves Sm,Med,Large,X-Large
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Dual USB car charger with 2x microUSB cables
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Tire Pressure Gauge
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2 Ballistic Vests
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ALL EMERGENCY LIGHTS WORKING
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Front Heat and AC Working?
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Rear Vent Working?
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Gas Cards Present?
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Marathon Card Present?
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UPMC East Card Present
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Entry Keys/The Oaks/152 Royal Oak Drive?
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Morning DECON Performed
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Vehicle Cleaned
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Interior Rear Lights Working?
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Any new damage to vehicle
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Drivers Sider Door ANSI Class II Vest
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Passenger Side Door ANSI Class II Vest
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Exterior Vehicle Lights Working? (Head lights,turn signals, etc)
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MDT with JetPack Present and Functioning?
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Is Cockpit clean?
Clip Board
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15 Patient Forms
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5 DOA Forms
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5 Refusal Forms
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2 Pens
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2 White Oak EMS Quick Registration Forms
House Bag/Oxygen/Portable Suction Cabinet
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Portable Suction Working
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Spare Battery
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Canister with Tubing
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2 Yankauer's
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8 French
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10 French
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12 French
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House Bag Top Tag #
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House Bag Red Medication Seal #
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House Bag Oxygen PSI
House Bag Front Compartment 1 Nasal Cannula 1 Nonrebreather 1 Nebulizer 1 Stethoscope 1 Adult BP Cuff 1 Pulse Oximeter 1 Glucometer w/ Strips and Lancets
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All Equipment Present?
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Missing Equipment?
Left Side Compartment 1 500 mL Bag nSS 1 Macrodrip Set 1 Pressure Infuser
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All Equipment Present?
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Missing Equipment?
Right Side Compartment 1 Small Sharps Container 1 Large Adult BP Cuff 1 CO Detector
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All Equipment Present?
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Missing Equipment?
Drug Box
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DRUG BOX TAG #
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Add media
Under the Bench Seat
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1 Spare Pillow
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1 Full Arm Splint
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Half Arm Splint
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Foot/Ankle Splint
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Full Leg Splint
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Half Leg Splint
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Hand/Wrist Splint
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1 Full E Cylinder with CPAP Connection
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PSI
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1 Bottle of Cleaning Wipes
Exterior Rear Passenger Side Compartment
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Smart Triage/Red Duffle Bag Tag #
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Add media
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1 KED
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2 PFDs
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1 Container Rock Salt (Winter)
Exterior Front Drivers Side Compartment
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6 Padded Board Splints (2 of each size)
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1 Reeves with a sheet
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1 PEDI Immobilizer
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1 ADULT/PEDI Traction Splint
Exterior Middle Drivers Side Compartment
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2 Hand Lights
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2 Helmets
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2 sets of turn out gear
Exterior Rear Drivers Side Compartment
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1 Scoop Stretcher
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2 Long Boards with straps
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2 sets of CID's with straps
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1 Collar Bag containing 12 collars, 2 of each size
Interior Shelf Area
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Main Oxygen PSI
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Add media
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Suction Working
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1 Sealed Yankauer
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10 HIPAA Forms
Interior
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2 Spare Oxygen Tanks
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PSI
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PSI
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1 Fire Extinguisher
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Temperatures of Drug Cabinet in Degrees
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Add media
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Rear Patient Area in Degrees
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Add media
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Medication Tag Log Book?
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Crew Member #1
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Crew Member #2