649 Ambulance Truck Check

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Daily Fluid Check

• Checked?

  Yes

  No

• Oil

  Full

  Low

• Antifreeze

  Full

  Low

• Transmission Fluid

  Full

  Low

• Break Fluid

  Full

  Low

• Windshield Fluid

  Full

  Low

• Steering Fluid

  Full

  Low

• Daily Fluid Check

  Passed

  Failed

Tire Pressures

• Checked?

  Checked

  Not Checked

• Driver's Side Front

• PSI

• Passenger Front

• PSI

• Driver's Rear Tire

• PSI

• Passenger Rear Tire

• PSI

• Treads OK?

  Yes

  No

Compartment A-1 6 emesis basins 6 bottles Sodium Chloride 3 Bags 1000 mL nSS

• Tag#

Compartment A-2 1 box tissues 6 bottles Sterile Water 1 humidifier kit 1 Purell

• Tag#

Compartment A-3 CPAP (tagged) 2 adult BVM 1 ANSII Class II Vest

• CPAP Tag #

• Compartment Tag#

Compartment A-4 1 spare CPAP Circuit 1 pocket mask 6 oral airways 5 nasal airways 4 adult NRB 4 adult Nasal Cannula 4 nebulizers 1 spare suction canister with tubing 2 adult simple mask 2 adult trach mask 2 O2 tubing 4 yankauer 1 each French 6,8,10,12,14,16,18 catheters 6 surgilube

• Tag#

Under Airway Seat

• 1 bedpan

• 1 urinal

• 1 traffic hazard kit

Compartment A-5 2 PPE Kits 1 box of N95 masks 3 burn sheets

• Tag#

Compartment A-6 5 trauma dressings 2 OB kits

• Tag#

Compartment A-7 5 hot packs 5 cold packs 1 Sam splint 10 triangular bandages 10 non-adhering dressing 1 roll sterile aluminum foil 5 brown paper bags 3 oral glucose 1 pen light 1 Thermometer with Covers 4 rolls assorted tape 1 roll hypoallergenic tape 1 razor 1 ring cutter 1 bulb syringe 10 drink cups 1 NIOSH book 1 Jane biohazard book 1 current emergency response guidebook

• Tag#

Compartment A-8 10 combine dressings 4 large Kling 4 small Kling 1 box 4x4 1 box 2x2 1 box bandaids 1 crash sheers 1 bandage sheers 1 spare monitor battery 1 roll monitor paper 1 D50 with expiration 5 9' straps 1 T-POD

• Tag#

Compartment A-9 Spare linen full

Compartment A-10 1 can Lysol 10 bio bags 1 roll disinfectant wipes

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

• 1 bottle Baby Aspirin

  Yes

  No

• Baby ASA expiration date

  Date

• 1 bottle Nitro Spray

  Yes

  No

• Nitro Spray expiration date

  Date

• Missing items

House Bag/Oxygen/Portable Suction Cabinet

• Portable suction working

  Yes

  No

• Spare battery

  Yes

  No

• Canister with tubing

  Yes

  No

• 2 Yankauer's

  Yes

  No

• 8 French

  Yes

  No

• 10 French

  Yes

  No

• 12 French

  Yes

  No

• BLS/ALS Protocol Book

  Yes

  No

• House bag top Tag #

• House Bag Red Medication Tag #

• House Bag Oxygen PSI

House Bag Front Compartment 1 Nasal Cannula 1 Nonrebreather 1 Nebulizer 1 Adult BP Cuff 1 Pulse Oximeter 1 Glucometer with Strips and Lancets 1 Stethoscope

• All Equipment Present?

  Yes

  No

  N/A

• Missing Equipment?

Left Side Compartment 1 500 mL bag nSS 1 Macrodrip Set 1 Pressure Infuser

• All Equipment Present?

  Yes

  No

  N/A

• Equipment Missing?

Right Side Compartment 1 Small Sharps Box 1 Large Adult BP Cuff 1 CO Detector

• All Equipment Present?

  Yes

  No

  N/A

• Equipment Missing?

Drug Box

• Drug box tag #

Under bench seat 2 CID Blocks with straps 1 reeves with sheet 1 Pedi immobilizer 1 Pedi traction splint 1 adult traction splint 1 KED 1 full arm splint 1 half arm splint 1 foot/ankle splint 1 full leg splint 1 1/2 leg splint 1 hand/wrist splint 6 padded board splints

• Pediatric bag seal #

• 1 spare oxygen cylinder PSI

• 12 cervical collars (6 various adult & 6 various pedi)

LP 15 Monitor

• Present and functioning

  Yes

  No

• Self test passed (tap white border and take photo of self test receipt)

  Yes

  No

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 cellular transmitter

• Battery 1

  Full

  Low

• Battery 2

  Full

  Low

• Any missing items

  Yes

  No

• Missing items

Above side door

• Medium gloves

• Large gloves

• Sharps container

Interior shelf area

• Main oxygen PSI

• Suction working

  Yes

  No

• 1 sealed yankauer

  Yes

  No

Below bench

• 2 long boards with straps

• 1 scoop stretcher

Compartment A-11

• 1 stair chair

Cockpit

• Vehicle inspection valid

  Yes

  No

• Mileage reading

• Fuel level

  Full

  3/4

  1/2

  1/4

  Empty

• Insurance/owners cards

  Yes

  No

• Garage door opener

  Yes

  No

• Map book

  Yes

  No

• GPS unit

  Yes

  No

• Personal CO detector

  Yes

  No

• Accident pack

  Yes

  No

• Non-latex gloves S,M,L,Xl

  Yes

  No

• Tire pressure gauge

  Yes

  No

• 2 PFD's

  Yes

  No

• All emergency lights working

  Yes

  No

• Front heat and A/C working

  Yes

  No

• Rear vent working

  Yes

  No

• Gas cards present

  Yes

  No

• Marathon Card Present

  Yes

  No

  N/A

• UPMC East card present

  Yes

  No

• Entry keys (the oaks, 152 royal oak dr

  Yes

  No

• Morning DECON performed

  Yes

  No

• Vehicle cleaned

  Yes

  No

• Interior rear lights working

  Yes

  No

• Any new damage to vehicle

  Yes

  No

• Driver's side door ANSI class II vest

  Yes

  No

• Passenger side door ANSI class II vest

  Yes

  No

• Exterior vehicle lights working (head lights, turn signals)

  Yes

  No

• Is cockpit clean

  Yes

  No

• MCI Kit

  Yes

  No

• MDT with Jetpack Present and Functioning

  Yes

  No

Clipboard

• 15 patient forms

  Yes

  No

• 5 DOA forms

  Yes

  No

• 5 refusal forms

  Yes

  No

• 2 pens

  Yes

  No

• 2 White Oak EMS Quick registration forms

  Yes

  No

• 10 HIPAA forms

  Yes

  No

Interior

• 2 spare oxygen tanks

  Yes

  No

• CPAP Cylinder PSI

• PSI

• 1 Fire Extinguisher

  Yes

  No

• Temperature of drug cabinet in degrees

• Rear patient area temperature

• Medication tag log book

  Yes

  No

• Crew member #1

  Sign

• Crew member #2

  Sign