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

  • Daily Fluid Check

Tire Pressures

  • Checked?

  • Driver's Side Front

  • PSI

  • Passenger Front

  • PSI

  • Driver's Rear Tire

  • PSI

  • Passenger Rear Tire

  • PSI

  • Treads OK?

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

  • Baby ASA expiration date

  • 1 bottle Nitro Spray

  • Nitro Spray expiration date

  • Missing items

House Bag/Oxygen/Portable Suction Cabinet

  • Portable suction working

  • Spare battery

  • Canister with tubing

  • 2 Yankauer's

  • 8 French

  • 10 French

  • 12 French

  • BLS/ALS Protocol Book

  • 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?

  • Missing Equipment?

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

  • All Equipment Present?

  • Equipment Missing?

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

  • All Equipment Present?

  • 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

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

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

  • Battery 2

  • Any missing items

  • Missing items

Above side door

  • Medium gloves

  • Large gloves

  • Sharps container

Interior shelf area

  • Main oxygen PSI

  • Suction working

  • 1 sealed yankauer

Below bench

  • 2 long boards with straps

  • 1 scoop stretcher

Compartment A-11

  • 1 stair chair

Cockpit

  • Vehicle inspection valid

  • Mileage reading

  • Fuel level

  • Insurance/owners cards

  • Garage door opener

  • Map book

  • GPS unit

  • EZ-PASS Present

  • Personal CO detector

  • Accident pack

  • Non-latex gloves S,M,L,Xl

  • Tire pressure gauge

  • 2 Ballistic Vests

  • 2 PFD's

  • All emergency lights working

  • Front heat and A/C working

  • Rear vent working

  • Gas cards present

  • Marathon Card Present

  • UPMC East card present

  • Entry keys (the oaks, 152 royal oak dr

  • Morning DECON performed

  • Vehicle cleaned

  • Interior rear lights working

  • Any new damage to vehicle

  • Driver's side door ANSI class II vest

  • Passenger side door ANSI class II vest

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

  • Is cockpit clean

  • MCI Kit

  • MDT with Jetpack Present and Functioning

Clipboard

  • 15 patient forms

  • 5 DOA forms

  • 5 refusal forms

  • 2 pens

  • 2 White Oak EMS Quick registration forms

  • 10 HIPAA forms

Interior

  • 2 spare oxygen tanks

  • CPAP Cylinder PSI

  • PSI

  • 1 Fire Extinguisher

  • Temperature of drug cabinet in degrees

  • Rear patient area temperature

  • Medication tag log book

  • Crew member #1

  • Crew member #2

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