House Bag/PEDI Bag

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Truck #

• Select date

  Date

House Bag Checklist

Main Compartment

Intubation Roll

• 1- Stethoscope

  Yes

  No

  N/A

• 1- 60cc Syringe

  Yes

  No

  N/A

King LTD (1 each)

• #2

  Yes

  No

  N/A

• #3

  Yes

  No

  N/A

• #4

  Yes

  No

  N/A

• #5

  Yes

  No

  N/A

ET Tubes

• (2) 6.0

  Yes

  No

  N/A

• (2) 6.5

  Yes

  No

  N/A

• (2) 7.0

  Yes

  No

  N/A

• (2) 7.5

  Yes

  No

  N/A

• (2) 8.0

  Yes

  No

  N/A

• 8.5

  Yes

  No

  N/A

• 9.0

  Yes

  No

  N/A

• 2- Adult Stylettes

  Yes

  No

  N/A

• 1- Magill Foreceps

  Yes

  No

  N/A

• 5- Surgi Lube

  Yes

  No

  N/A

• 4- Spare Bulbs

  Yes

  No

  N/A

• 1- Roll 1" Tape

  Yes

  No

  N/A

• MAC 3

  Yes

  No

  N/A

• MAC 4

  Yes

  No

  N/A

• MIL 2

  Yes

  No

  N/A

• MIL 3

  Yes

  No

  N/A

• Mil 4

  Yes

  No

  N/A

• 1- Laryngoscope Handle

  Yes

  No

  N/A

• 2- 10cc Syringes

  Yes

  No

  N/A

• 1- ETCO2 Detector

  Yes

  No

  N/A

• 2- Adult Tube Holders

  Yes

  No

  N/A

• 1- Tube (Bulb) Checker

  Yes

  No

  N/A

• 4- Oral Airways

  Yes

  No

  N/A

• 1- Biohazard Bag

  Yes

  No

  N/A

• 2- Spare C Batteries

  Yes

  No

  N/A

• EZ IO Drill w/case<br>1 Adult Needle<br>2 Pediatric Needles

  Yes

  No

  N/A

• Adult Bag Valve Mask

  Yes

  No

  N/A

• Oxygen Cylinder PSI

Medication Pouch

• Old Tag #

6- Epi 1:10,000

• Epi 1 exp date

  Yes

  No

  N/A

• Epi 2 exp date

  Yes

  No

  N/A

• Epi 3 exp date

  Yes

  No

  N/A

• Epi 4 exp date

  Yes

  No

  N/A

• Epi 5 exp date

  Yes

  No

  N/A

• Epi 6 exp date

  Yes

  No

  N/A

2- Atropine

• Atropine 1 exp date

  Yes

  No

  N/A

• Atropine 2 exp date

  Yes

  No

  N/A

• D50 exp date

  Yes

  No

  N/A

• Narcan 1 exp date

  Yes

  No

  N/A

• Narcan 2 exp date

  Yes

  No

  N/A

• Lidocaine 1 exp date

  Yes

  No

  N/A

• Lidocaine 2 exp date

  Yes

  No

  N/A

• GlucaGen 1 exp date

  Yes

  No

  N/A

• Albuterol 1 exp date

  Yes

  No

  N/A

• Albuterol 2 exp date

  Yes

  No

  N/A

• Ipratropium Bromide 1 exp date

  Yes

  No

  N/A

• Ipratropium Bromide 2 exp date

  Yes

  No

  N/A

• Epi 1:1,000 exp date

  Yes

  No

  N/A

• 1- Solu-medrol Exp Date

  Yes

  No

  N/A

• 1- Zofran exp date

  Yes

  No

  N/A

• 1- Benadryl exp date

  Yes

  No

  N/A

• Adenosine Exp Date

  Yes

  No

  N/A

• Amiodarone Exp Date

  Yes

  No

  N/A

• Amiodarone Exp Date

  Yes

  No

  N/A

• 1- Bottle Baby Aspirin exp date

  Yes

  No

  N/A

• 1- Nitro Spray exp date

  Yes

  No

  N/A

• 1- Oral Glucose exp date

  Yes

  No

  N/A

IV Pouch

• Old Tag #

• 1- Roll 1" Tape

  Yes

  No

  N/A

• 5- Opsites

  Yes

  No

  N/A

• 2- Extension Sets

  Yes

  No

  N/A

• 2- Flushes

  Yes

  No

  N/A

• 5- Alcohol Wipes

  Yes

  No

  N/A

2 Each IV Catheters

• 14ga

  Yes

  No

  N/A

• 16ga

  Yes

  No

  N/A

• 18ga

  Yes

  No

  N/A

• 20ga

  Yes

  No

  N/A

• 22ga

  Yes

  No

  N/A

• 24ga

  Yes

  No

  N/A

• 2- IV Start Kits

  Yes

  No

  N/A

• 1- Tourniquet

  Yes

  No

  N/A

• 2 Each Syringes

• (2) 1cc

  Yes

  No

  N/A

• (2) 3cc

  Yes

  No

  N/A

• (2) 5cc

  Yes

  No

  N/A

• (2) 10cc

  Yes

  No

  N/A

• 2 Each Needles

• (2) 18ga

  Yes

  No

  N/A

• (2) 22ga

  Yes

  No

  N/A

• (2) 25ga

  Yes

  No

  N/A

• 1- MADD Device

  Yes

  No

  N/A

Inside Mesh Compartment

• 10 Small Bandaids<br>10 Large Bandaids<br>2 Kling (1 Large, 1 Small)<br>4 Abdominal Pads<br>5 2x2<br>5 4x4<br>4 Petroleum Dressings<br>2 Ice Packs<br>Pen Light<br>1 Inch Tape

  Yes

  No

  N/A

• Equipment Missing?

Top Mesh Compartment

• 1 Burn Sheet 2 Trauma Dressings Trauma Sheers Bandage Sheers 1 Commercial Tourniquet with Marker

Left Side Pouch

• 500 mL bag nSS Exp Date:

  Yes

  No

  N/A

• Macrodrip Set

  Yes

  No

  N/A

• Pressure Infuser

  Yes

  No

  N/A

Right Side Pouch

• 1 Small Sharp Container

  Yes

  No

  N/A

• 1 Large Adult BP Cuff

  Yes

  No

  N/A

• CO Detector (TEST)

  Yes

  No

  N/A

Front Pouch

• 1 Nasal Cannula

  Yes

  No

  N/A

• 1 Non-Rebreather

  Yes

  No

  N/A

• 1 Nebulizer

  Yes

  No

  N/A

• 1 Stethoscope

  Yes

  No

  N/A

• Adult BP Cuff

  Yes

  No

  N/A

• Glucometer with Strips and Lancets

  Yes

  No

  N/A

• Pulse Oximeter

  Yes

  No

  N/A

Pedi Bag Checklist

• 5 Pedi Blades Needed

• Mac 0

  Yes

  No

  N/A

• Mac 1

  Yes

  No

  N/A

• Mac 2

  Yes

  No

  N/A

• Mil 0

  Yes

  No

  N/A

• Mil 1

  Yes

  No

  N/A

• Mil 2

  Yes

  No

  N/A

• 1- Racemic Epi exp date

  Yes

  No

  N/A

• 1- 10cc syringe

  Yes

  No

  N/A

• Laryngoscope Handle

  Yes

  No

  N/A

• Spare Bulbs (4)

  Yes

  No

  N/A

• Spare AA Batteries (2)

  Yes

  No

  N/A

• Pen Light

  Yes

  No

  N/A

• Surgi Lube(5)

  Yes

  No

  N/A

• Oral Airways (4) Misc

  Yes

  No

  N/A

• Magill Forceps

  Yes

  No

  N/A

• ALL BULBS WORKING?

  Yes

  No

  N/A

ET Tubes

• King LT Size 2

  Yes

  No

  N/A

• 2.5 (2)

  Yes

  No

  N/A

• 3.0 (2)

  Yes

  No

  N/A

• 3.5 (2)

  Yes

  No

  N/A

• 4.0 (2)

  Yes

  No

  N/A

• 4.5 (2)

  Yes

  No

  N/A

• 5.0 (2)

  Yes

  No

  N/A

• 5.5 (2)

  Yes

  No

  N/A

• 6.0 (2)

  Yes

  No

  N/A

• Minimum 2 Pedi Stylettes

  Yes

  No

  N/A

• 1- Large Stylette

  Yes

  No

  N/A

• 2- Pedi Tube Holders

  Yes

  No

  N/A

• 1- Pedi ETCO2 Detector

  Yes

  No

  N/A

IV Needles

• 2-20ga

  Yes

  No

  N/A

• 2-22ga

  Yes

  No

  N/A

• 2-24ga

  Yes

  No

  N/A

• 2- Saline Flushes

  Yes

  No

  N/A

• 1- 20 Drip

  Yes

  No

  N/A

• 1- 60 Drip

  Yes

  No

  N/A

• 500 NSS and exp date

  Yes

  No

  N/A

• Pedi Wheel

  Yes

  No

  N/A

• Broselow Tape

  Yes

  No

  N/A

• Pedi/Infant O2 Sensor (1 ea)

  Yes

  No

  N/A

• 1- Infant Non-Rebreather

  Yes

  No

  N/A

• 2- Pedi Non-Rebreathers

  Yes

  No

  N/A

• 2- Pedi Nasal Cannulas

  Yes

  No

  N/A

• 1- Pedi Trach Mask

  Yes

  No

  N/A

• Meconium Aspirator

  Yes

  No

  N/A

• 1- Pedi B/P Cuff

  Yes

  No

  N/A

• 1- Pedi Stethoscope

  Yes

  No

  N/A

• 2- Pedi BVM's

  Yes

  No

  N/A

• 1- Pedi Quick Combo Pads

  Yes

  No

  N/A

• 12 Pedi Electrodes

  Yes

  No

  N/A

• 5- 4x4's

  Yes

  No

  N/A

• 5- 2x2's

  Yes

  No

  N/A

• 5- Opsites

  Yes

  No

  N/A

• 2- IV Start Kits

  Yes

  No

  N/A

• 10- Alcohol Wipes

  Yes

  No

  N/A

• 2- Extension Sets

  Yes

  No

  N/A

• 1- 1/2" Tape

  Yes

  No

  N/A

• 1- 1" Tape

  Yes

  No

  N/A

• Arm Board

  Yes

  No

  N/A

• NEW TAG(s)#

Trauma Bag Checklist

• 8- Combine Dressings

  Yes

  No

  N/A

• 1- T-POD pelvic stabilization device

  Yes

  No

  N/A

• 1- Commercial Grade Tourniquet

  Yes

  No

  N/A

• 5- Non-Adhering Dressings

  Yes

  No

  N/A

• 2- Trauma Dressing

  Yes

  No

  N/A

• 1- Burn Sheet

  Yes

  No

  N/A

• 1- 1000 NSS exp date

  Yes

  No

  N/A

• 2- 20 Drip Sets

  Yes

  No

  N/A

• 2- Non-Latex Tourniquets

  Yes

  No

  N/A

IV Catheters

• 2- 14ga

  Yes

  No

  N/A

• 2- 16ga

  Yes

  No

  N/A

• 2- 18ga

  Yes

  No

  N/A

• 1- Pen Light

  Yes

  No

  N/A

• 1- Sharps Container

  Yes

  No

  N/A

• 1- Bottle Sterile Water exp date

  Yes

  No

  N/A

• 5- Large Kling

  Yes

  No

  N/A

• 1- Pair Crash Shears

  Yes

  No

  N/A

• 1- Pair Bandage Shears

  Yes

  No

  N/A

• 10- 2x2's

  Yes

  No

  N/A

• 10- 4x4's

  Yes

  No

  N/A

• 1- Box Band Aids

  Yes

  No

  N/A

• 1- Roll 1"Tape

  Yes

  No

  N/A

• 1- Roll 2"Tape

  Yes

  No

  N/A

• 2- Saline Flushes

  Yes

  No

  N/A

• 1- 10cc Syringe

  Yes

  No

  N/A

• 1- Stethoscope

  Yes

  No

  N/A

• 2- IV Start Kits

  Yes

  No

  N/A

• 5- OpSites

  Yes

  No

  N/A

• 2- Extension Kits

  Yes

  No

  N/A

• 1- Pressure Infuser

  Yes

  No

  N/A

• OLD TRAUMA BAG TAG#'s

• NEW TRAUMA BAG TAG#'s

  Yes

  No

  N/A

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