General / Professional Liability

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

Claimant Details

• First Name:

• Last Name:

• Primary Claimant:

  Patient

  Next of Kin

  Civilian

  Landlord / Lessee

  Other

• Home Address:

• City:

• State:

• Zip Code:

• Home Phone:

• Other Telephone:

• Date of Birth:

  Date

• Attachment:

  Media

Incident Summary

• Type of Claim:

  Select Response/Scene/Transport Times Clinical Errors or Omissions Patient Injury during AMR Service Choice of Destination Facility Damaged, Stolen, Lost Property Medical Equipment Failure causing harm Other Claim Brought by Patient Personal Injury to Non-Patient

  • Response/Scene/Transport Times
  • Clinical Errors or Omissions
  • Patient Injury during AMR Service
  • Choice of Destination Facility
  • Damaged, Stolen, Lost Property
  • Medical Equipment Failure causing harm
  • Other Claim Brought by Patient
  • Personal Injury to Non-Patient

• County:

• Department

  Select Administration Communications HR Operations Fleet Payroll Safety and Risk

  • Administration
  • Communications
  • HR
  • Operations
  • Fleet
  • Payroll
  • Safety and Risk

• Incident Date:

  Date

• Supervisor Notified On:

  Date

• SRM Notified On:

  Date

• Reported to SRM By:

• AMR Call or PCR Number:

• Call Type:

  Select Emergency 911 (ALS) Emergency 911 (BLS) Non-Emergent (ALS) Non- Emergent (BLS) Critical Care (CCT) Mobile Healthcare Wheelchair Service Call No Specific Call Other

  • Emergency 911 (ALS)
  • Emergency 911 (BLS)
  • Non-Emergent (ALS)
  • Non- Emergent (BLS)
  • Critical Care (CCT)
  • Mobile Healthcare
  • Wheelchair Service Call
  • No Specific Call
  • Other

• Equipment in Use:

  Select Gurney (Manual) Gurney (Power) Stair Chair Flat/Scoop/Backboard Wheelchair Other PT lifting/Moving Device Vehicle Monitor/Defibrillator Unit Medical Sharp (IV Catheter, Lance)

  • Gurney (Manual)
  • Gurney (Power)
  • Stair Chair
  • Flat/Scoop/Backboard
  • Wheelchair
  • Other PT lifting/Moving Device
  • Vehicle
  • Monitor/Defibrillator Unit
  • Medical Sharp (IV Catheter, Lance)

• Equipment Model Number:

• Alleged Action:

  Select Dispatching Error Vehicle Failure During Call Gurney Drop/Incident with Patient Non-Gurney Patient drop with Injury Non-Gurney Patient drop with injury Racism/Discrimination during call Esophageal intubation/ Bad Tube Wrong Medication or Wrong Dose Treating without proper consent Failure to adequately C-Spine Patient Walking the patient causing harm Wrong destination/facility selected Failure to treat/Refusal to Transport Failure to Transport / AMA bad outcome Other protocol deviation causing harm Excessive Force - AMR ONLY Excessive Force - Allied Agency/AMR Unlawful Restraint Alleged Sexual Misconduct PT death while on mental health hold Willful intent to harm/malicious action Other Clinical error/omission Other non-clinical error/omission Gurney damage to other property

  • Dispatching Error
  • Vehicle Failure During Call
  • Gurney Drop/Incident with Patient
  • Non-Gurney Patient drop with Injury
  • Non-Gurney Patient drop with injury
  • Racism/Discrimination during call
  • Esophageal intubation/ Bad Tube
  • Wrong Medication or Wrong Dose
  • Treating without proper consent
  • Failure to adequately C-Spine Patient
  • Walking the patient causing harm
  • Wrong destination/facility selected
  • Failure to treat/Refusal to Transport
  • Failure to Transport / AMA bad outcome
  • Other protocol deviation causing harm
  • Excessive Force - AMR ONLY
  • Excessive Force - Allied Agency/AMR
  • Unlawful Restraint
  • Alleged Sexual Misconduct
  • PT death while on mental health hold
  • Willful intent to harm/malicious action
  • Other Clinical error/omission
  • Other non-clinical error/omission
  • Gurney damage to other property

• Allegation Made By:

  Select Patient Patient Attorney Patient Family Member Patient Friend/Neighbor Patient Advocate/Rep-Other Fire Department Witness Law Enforcement Witness 3rd Party Witness Doctor/Other Medical Person on Scene Receiving Hospital Physician/Staff Self Reported by Employee(s) Identified by AMR internal QA/QI EMS Agency/External Regulator Other- only if not listed above

  • Patient
  • Patient Attorney
  • Patient Family Member
  • Patient Friend/Neighbor
  • Patient Advocate/Rep-Other
  • Fire Department Witness
  • Law Enforcement Witness
  • 3rd Party Witness
  • Doctor/Other Medical Person on Scene
  • Receiving Hospital Physician/Staff
  • Self Reported by Employee(s)
  • Identified by AMR internal QA/QI
  • EMS Agency/External Regulator
  • Other- only if not listed above

• Alleged Harm:

  Select No identified physical/mental harm Death/Wrongful Death Loss of Key Organ (eyes,ear,nose,etc.) Loss of limb(s) Paralysis/Nerve Damage Brain/Mental Damage Fracture Contusion/Abrasion/Laceration Increased Pain & Suffering Inconvenience/Basic Stress Delayed recovery/Increased expense Other physical injury caused by AMR Exposure/Disease caused by AMR Emotional/Mental Harm (non-physical) Property Damage Loss of Property/Loss of use Other

  • No identified physical/mental harm
  • Death/Wrongful Death
  • Loss of Key Organ (eyes,ear,nose,etc.)
  • Loss of limb(s)
  • Paralysis/Nerve Damage
  • Brain/Mental Damage
  • Fracture
  • Contusion/Abrasion/Laceration
  • Increased Pain & Suffering
  • Inconvenience/Basic Stress
  • Delayed recovery/Increased expense
  • Other physical injury caused by AMR
  • Exposure/Disease caused by AMR
  • Emotional/Mental Harm (non-physical)
  • Property Damage
  • Loss of Property/Loss of use
  • Other

• 1st Body Part Affected:

  Select Head Eye Ear Nose Facial Mouth/Teeth Neck-Soft tissue Back/Spine Shoulder Elbow Wrist Finger Thumb Hand Hip Knee Ankle Arm-Humerous (upper) Arm-Radius/Ulna (Forearm) Chest/Ribs Abdomen/Pelvis Buttocks Leg-Femur Leg-Tibula/Fibula Foot Toe(s) Internal Organ(s) Psychological Multiple All Others Invalid/undefined

  • Head
  • Eye
  • Ear
  • Nose
  • Facial
  • Mouth/Teeth
  • Neck-Soft tissue
  • Back/Spine
  • Shoulder
  • Elbow
  • Wrist
  • Finger
  • Thumb
  • Hand
  • Hip
  • Knee
  • Ankle
  • Arm-Humerous (upper)
  • Arm-Radius/Ulna (Forearm)
  • Chest/Ribs
  • Abdomen/Pelvis
  • Buttocks
  • Leg-Femur
  • Leg-Tibula/Fibula
  • Foot
  • Toe(s)
  • Internal Organ(s)
  • Psychological
  • Multiple
  • All Others
  • Invalid/undefined

• 1st Body Part Aspect:

  Select Left Right Both Left and Right Neck-Spine Upper Spine-thoracic Lower Spine-lumbar Not Applicable Unknown at this time

  • Left
  • Right
  • Both Left and Right
  • Neck-Spine
  • Upper Spine-thoracic
  • Lower Spine-lumbar
  • Not Applicable
  • Unknown at this time

• 2nd Body Part Affected:

  Select Head Eye Ear Nose Facial Mouth/Teeth Neck-Soft tissue Back/Spine Shoulder Elbow Wrist Finger Thumb Hand Hip Knee Ankle Arm-Humerous (upper) Arm-Radius/Ulna (Forearm) Chest/Ribs Abdomen/Pelvis Buttocks Leg-Femur Leg-Tibula/Fibula Foot Toe(s) Internal Organ(s) Psychological Multiple All Others Invalid/undefined

  • Head
  • Eye
  • Ear
  • Nose
  • Facial
  • Mouth/Teeth
  • Neck-Soft tissue
  • Back/Spine
  • Shoulder
  • Elbow
  • Wrist
  • Finger
  • Thumb
  • Hand
  • Hip
  • Knee
  • Ankle
  • Arm-Humerous (upper)
  • Arm-Radius/Ulna (Forearm)
  • Chest/Ribs
  • Abdomen/Pelvis
  • Buttocks
  • Leg-Femur
  • Leg-Tibula/Fibula
  • Foot
  • Toe(s)
  • Internal Organ(s)
  • Psychological
  • Multiple
  • All Others
  • Invalid/undefined

• Number of Witnesses:

• Law Enforcement:

  Involved, report pending

  Involved, report received

  Involved, not doing a report

  Not involved

• Law Agency:

• Case/Incident:

• Brief Summary:

• Attachment:

  Media

Employee Detail

• Employee 1 - Last, First:

• Select Dispatcher Lead ALS care provider ALS partner/driver Lead BLS care provider BLS partner/driver CCT nurse/care provider CCT unit ALS/BLS support Field Training Officer (FTO) AMR Supervisor on-scene Mobile Healthcare Provider Wheelchair Unit Driver Management / Administrative- General Other

  • Dispatcher
  • Lead ALS care provider
  • ALS partner/driver
  • Lead BLS care provider
  • BLS partner/driver
  • CCT nurse/care provider
  • CCT unit ALS/BLS support
  • Field Training Officer (FTO)
  • AMR Supervisor on-scene
  • Mobile Healthcare Provider
  • Wheelchair Unit Driver
  • Management / Administrative- General
  • Other

• Date of Hire:

  Date

• SSN:

• DOB:

  Date

• Gender:

  Male

  Female

• Employment Status:

  Full Time

  Part Time

  Seasonal

  Temporary

• Occupation Code:

  Select EMT Paramedic Nurse Field/Admin Supervisor Dispatcher Wheelchair Technician VST Mechanic Courier/Driver Admin/Clerical Support Management Gurney/Stretcher Driver Medical Examiner Transport First Responder All Others N/a

  • EMT
  • Paramedic
  • Nurse
  • Field/Admin Supervisor
  • Dispatcher
  • Wheelchair Technician
  • VST
  • Mechanic
  • Courier/Driver
  • Admin/Clerical Support
  • Management
  • Gurney/Stretcher Driver
  • Medical Examiner Transport
  • First Responder
  • All Others
  • N/a

• Employee Number 2- Last, First

• Employee 2 Role in Incident:

  Select Dispatcher Lead ALS care provider ALS partner/driver Lead BLS care provider BLS partner/driver CCT nurse/care provider CCT unit ALS/BLS support Field Training Officer (FTO) AMR Supervisor on-scene Mobile Healthcare Provider Wheelchair Unit Driver Management / Administrative- General Other

  • Dispatcher
  • Lead ALS care provider
  • ALS partner/driver
  • Lead BLS care provider
  • BLS partner/driver
  • CCT nurse/care provider
  • CCT unit ALS/BLS support
  • Field Training Officer (FTO)
  • AMR Supervisor on-scene
  • Mobile Healthcare Provider
  • Wheelchair Unit Driver
  • Management / Administrative- General
  • Other

• Date of Hire:

  Date

• SSN:

• DOB:

  Date

• Gender:

  Male

  Female

• Employment Status:

  Full Time

  Part Time

  Seasonal

  Temporary

• Occupation Code:

  Select Dispatcher Lead ALS care provider ALS partner/driver Lead BLS care provider BLS partner/driver CCT nurse/care provider CCT unit ALS/BLS support Field Training Officer (FTO) AMR Supervisor on-scene Mobile Healthcare Provider Wheelchair Unit Driver Management / Administrative- General Other

  • Dispatcher
  • Lead ALS care provider
  • ALS partner/driver
  • Lead BLS care provider
  • BLS partner/driver
  • CCT nurse/care provider
  • CCT unit ALS/BLS support
  • Field Training Officer (FTO)
  • AMR Supervisor on-scene
  • Mobile Healthcare Provider
  • Wheelchair Unit Driver
  • Management / Administrative- General
  • Other

• Attachment:

  Media

Supervisor Detail

• Supervisor Name:

• Supervisor Phone Number:

• Supervisor E-Mail:

• EMS Protocols:

  All protocols were followed

  EMS protocols potentially violated

  No EMS protocol is applicable

  Unknown - Under Investigation

• AMR Policy:

  All Policies were followed

  AMR Policy(ies) Violated

  No AMR Policy is applicable

  Unknown - Under Investigation

• Corrective Action:

  Corrective Action is Needed

  No Type of Corrective Action is Needed

  Unknown at this time

• Action Plan EE1

  Select Remedial Education/Training Disciplinary Action Performance Improvement Plan (PIP) Combo of Discipline & Education/Training Other Documented Corrective Action Not Applicable Unknown at this time

  • Remedial Education/Training
  • Disciplinary Action
  • Performance Improvement Plan (PIP)
  • Combo of Discipline & Education/Training
  • Other Documented Corrective Action
  • Not Applicable
  • Unknown at this time

• Date Completed EE1

• Action Plan EE2:

  Select Remedial Education/Training Disciplinary Action Performance Improvement Plan (PIP) Combo of Discipline & Education/Training Other Documented Corrective Action Not Applicable Unknown at this time

  • Remedial Education/Training
  • Disciplinary Action
  • Performance Improvement Plan (PIP)
  • Combo of Discipline & Education/Training
  • Other Documented Corrective Action
  • Not Applicable
  • Unknown at this time

• Date Completed EE2:

• ETOH/Drug Test:

  Done, Negative Result

  Done, Positive Result (Include Note)

  Expected, Results Pending

  Not Applicable

• Attachments:

  Media

• Comments: