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
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Truck #
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Select date
House Bag Checklist
Intubation Kit (Red Seal)
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Pouch Tag #
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1- Stethoscope
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1- 60cc Syringe
King LTD (1 each)
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#3
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#4
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#5
ET Tubes (1 each) except where marked
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6.0
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6.5
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(2) 7.0
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(2) 7.5
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8.0
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8.5
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9.0
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2- Adult Stylettes
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1- Magill Foreceps
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5- Surgi Lube
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4- Spare Bulbs
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1- Roll 1" Tape
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MAC 3
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MAC 4
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MIL 2
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MIL 3
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Mil 4
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1- Laryngoscope Handle
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2- 10cc Syringes
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1- ETCO2 Detector
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2- Adult Tube Holders
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1- Tube (Bulb) Checker
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4- Oral Airways
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1- Biohazard Bag
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2- Spare C Batteries
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Right Side Pouch Tag#
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1000 NSS
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1000 NSS Exp Date
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Top Pouch Tag#
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1- Sharps Container
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1- Adult BVM
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2- Cold Packs
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2- Rolls 1" Tape
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1- Bottle Sterile Water
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1- Large B/P Cuff
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1- Pen Light
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Left Side Pouch Tag#
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EZ IO Drill w/case
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2- Pedi Needles
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1- Adult Needle
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Bandage Pouch Tag#
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3- Combine Dressings
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1- Bandage Shears
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1- Crash Shears
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5- 4x4's
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5- 2x2's
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4- Non Adhering Dressings
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10- Small Bandages
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10- Large Bandages
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1- Small Kling
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1- Large Kling
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1- Roll 1" Tape
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Drug Pouch Tag#
6- Epi 1:10,000
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Epi 1 exp date
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Epi 2 exp date
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Epi 3 exp date
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Epi 4 exp date
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Epi 5 exp date
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Epi 6 exp date
3- Atropine
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Atropine 1 exp date
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Atropine 2 exp date
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Atropine 3 exp date
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D50 exp date
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Narcan 1 exp date
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Narcan 2 exp date
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Lidocaine 1 exp date
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Lidocaine 2 exp date
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GlucaGen 1 exp date
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GlucaGen 2 exp date
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Albuterol 1 exp date
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Albuterol 2 exp date
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Ipratropium Bromide 1 exp date
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Ipratropium Bromide 2 exp date
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Epi 1:1,000 exp date
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1- Solu-medrol
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1- Zofran exp date
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1- Benadryl exp date
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1- Bottle Baby Aspirin exp date
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1- Nitro Spray exp date
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1- Oral Glucose exp date
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1- Roll 1" Tape
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5- Opsites
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2- Extension Sets
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2- Flushes
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5- SurgiLube
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5- Alcohol Wipes
2 Each IV Catheters
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14ga
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16ga
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18ga
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20ga
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22ga
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24ga
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2- IV Start Kits
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1- Tourniquet
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BEHIND THE ZIPPER IN THE DRUG POUCH SIDE (2 each syringes)
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1cc
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3cc
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5cc
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10cc
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2 Each Needles
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18ga
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22ga
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25ga
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1- MADD Device
Pedi Bag Checklist
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5 Pedi Blades Needed
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Mac 0
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Mac 1
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Mac 2
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Mil 0
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Mil 1
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Mil 2
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1- Racemic Epi exp date
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1- 10cc syringe
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Laryngoscope Handle
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Spare Bulbs (4)
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Spare AA Batteries (2)
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Pen Light
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Surgi Lube(5)
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Oral Airways (4) Misc
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Magill Forceps
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ALL BULBS WORKING?
ET Tubes
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2.5
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3.0
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3.5 (2)
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4.0
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4.5
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5.0
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5.5
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6.0
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Minimum 2 Pedi Stylettes
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1- Large Stylette
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2- Pedi Tube Holders
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1- Pedi ETCO2 Detector
IV Needles
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2-20ga
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2-22ga
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2-24ga
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2- Saline Flushes
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1- 20 Drip
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1- 60 Drip
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500 NSS and exp date
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Pedi Wheel
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Broselow Tape
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Pedi/Infant O2 Sensor (1 ea)
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1- Infant Non-Rebreather
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2- Pedi Non-Rebreathers
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2- Pedi Nasal Cannulas
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1- Pedi Trach Mask
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Meconium Aspirator
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1- Pedi B/P Cuff
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1- Pedi Stethoscope
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2- Pedi BVM's
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1- Pedi Quick Combo Pads
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12 Pedi Electrodes
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5- 4x4's
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5- 2x2's
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5- Opsites
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2- IV Start Kits
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10- Alcohol Wipes
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2- Extension Sets
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1- 1/2" Tape
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1- 1" Tape
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Arm Board
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NEW TAG(s)#
Trauma Bag Checklist
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8- Combine Dressings
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1- T-POD pelvic stabilization device
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1- Commercial Grade Tourniquet
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5- Non-Adhering Dressings
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2- Trauma Dressing
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1- Burn Sheet
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1- 1000 NSS exp date
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2- 20 Drip Sets
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2- Non-Latex Tourniquets
IV Catheters
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2- 14ga
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2- 16ga
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2- 18ga
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1- Pen Light
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1- Sharps Container
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1- Bottle Sterile Water exp date
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5- Large Kling
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1- Pair Crash Shears
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1- Pair Bandage Shears
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10- 2x2's
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10- 4x4's
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1- Box Band Aids
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1- Roll 1"Tape
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1- Roll 2"Tape
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2- Saline Flushes
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1- 10cc Syringe
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1- Stethoscope
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2- IV Start Kits
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5- OpSites
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2- Extension Kits
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1- Pressure Infuser
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OLD TRAUMA BAG TAG#'s
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NEW TRAUMA BAG TAG#'s
Crew Member Signatures
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