TSC EMT MedTech 2016

• Audit Title

• Job No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Security and PHI Control

• Is the medical office secure?

  Yes

  No

  N/A

• Additional Comments

• What type of security is in place for the medical office?

  Yes

  No

  N/A

• Additional Comments

• Are keys used? If keys are used to access the Med Office, who has copies?

  Yes

  No

  N/A

• Additional Comments

• Is there a paper shredder on site?

  Yes

  No

  N/A

• Additional Comments

• Are all PHI documents removed and stored at the end of the work day? If yes, where are they stored (i.e. locked file cabinet)?

  Yes

  No

  N/A

• Additional Comments

• Is the paper shredder used for destruction of the PHI that is not needed?

  Yes

  No

  N/A

• Additional Comments

• Is the laptop or desktop computer secured at night?

  Yes

  No

  N/A

• Additional Comments

• Is the laptop or desktop computer encrypted?

  Yes

  No

  N/A

• Additional Comments

• Does the Medtech person have a current Hippa certificate?

  Yes

  No

  N/A

• Additional Comments

• Is the laptop or desktop computer encrypted?

  Yes

  No

  N/A

• Additional Comments

Personal Certifications and Training

• Does the provider have a current EMT Card on their person? If so, Date of Expiration?

  Yes

  No

  N/A

• Additional Comments.

• Does the provider have a current OSHA 10 card on their person? If so, Date of Expiration?

  Yes

  No

  N/A

• Additional Comments.

• Does the provider have a current CPR Card on their person? If so, Date of Expiration?

  Yes

  No

  N/A

• Additional Comments.

• List any other certification cards

• Are these certifications entered into Sugar CRM and, subsequently, is HR made aware?

  Yes

  No

  N/A

• Additional Comments.

Provider Appearance

• Does the provider present neatly?

  Yes

  No

  N/A

• Additional Comments

• Does the providers attire appear neat and professional?

  Yes

  No

  N/A

• Additional Comments

• Is the provider wearing appropriate Medtech shirt or vest?

  Yes

  No

  N/A

• Additional Comments

• Is the provider wearing competitor (of Client or of Medtech) apparel?

  Yes

  No

  N/A

• Additional Comments

• Is the provider wearing appropriate PPE?

  Yes

  No

  N/A

• Additional Comments

• Does the provider need replacement PPE?

  Yes

  No

  N/A

• Additional Comments

Medical Facility Exterior Appearance

• If in a trailer, is the exterior of the trailer clean and free of debris around it?

  Yes

  No

  N/A

• Additional Comments

• Is the entrance way free of obstructions and staged materials?

  Yes

  No

  N/A

• Additional Comments

• Is there identifying signage for the clinic posted on the exterior?

  Yes

  No

  N/A

• Additional Comments

• Is the signage professional in appearance and clearly readable?

  Yes

  No

  N/A

• Additional Comments

• Is there adequate lighting in the outside entrance area?

  Yes

  No

  N/A

• Additional Comments

Medical Facility Interior Appearance

• Upon entering the Medical Trailer or Facility, does it appear professional?

  Yes

  No

  N/A

• Additional Comments

• Is the floor surface clean and free of debris?

  Yes

  No

  N/A

• Additional Comments

• Is the garbage receptacle clean and not over flowing?

  Yes

  No

  N/A

• Additional Comments

• Is the regulated waste stored as per stericycle guidelines?

  Yes

  No

  N/A

• Additional Comments

• Are personal effects and items stored properly?

  Yes

  No

  N/A

• Additional Comments

• Is the exam table clean and papered?

  Yes

  No

  N/A

• Additional Comments

• Are the microwave and refrigerator clean and in good repair?

  Yes

  No

  N/A

• Additional Comments

• Are the medicine storage shelves clean, neat and organized?

  Yes

  No

  N/A

• Additional Comments

• Are counter tops and or desktops free of debris, old food stuffs, wrappers etc.?

  Yes

  No

  N/A

• Additional Comments

• Is the daily cleaning checklist being utilized?

  Yes

  No

  N/A

• Additional Comments

• Is there an adequate supply of appropriate cleaning products on hand?

  Yes

  No

  N/A

• Additional Comments

MedTech Paperwork

• Is there a digital copy of the MedTech protocols onsite?

  Yes

  No

  N/A

• Additional Comments

• Are signatures being obtained on all PCR’s?

  Yes

  No

  N/A

• Additional Comments

• Are PCR’s being fully completed?

  Yes

  No

  N/A

• Additional Comments

• Are signatures being obtained on Hippa release forms?

  Yes

  No

  N/A

• Additional Comments

• Are signatures being obtained on all RMA’s?

  Yes

  No

  N/A

• Additional Comments

• Is the trauma bag check list being followed?

  Yes

  No

  N/A

• Additional Comments

• Is the medication checklist being utilized?

  Yes

  No

  N/A

• Additional Comments

• Are expired medications disposed of properly?

  Yes

  No

  N/A

• Additional Comments

• Are copies of supply orders onsite?

  Yes

  No

  N/A

• Additional Comments

• Is a digital copy of the TSC Field Manual available on site?

  Yes

  No

  N/A

• Additional Comments

• Is a site specific operations manual on-site?

  Yes

  No

  N/A

• Additional Comments

• Is all client related reports being completed in timely manner?

  Yes

  No

  N/A

• Additional Comments

• Is the provider's daily log being completed?

  Yes

  No

  N/A

• Additional Comments

• Are patient follow-up notes being properly recorded?

  Yes

  No

  N/A

• Additional Comments

• Is the trauma bag checklist being used?

  Yes

  No

  N/A

• Additional Comments

• Are patient return-to-work notes being obtained and filed?

  Yes

  No

  N/A

• Additional Comments

• As per the PCR is treatment or referral in accordance with protocol?

  Yes

  No

  N/A

• Additional Comments

TSC

• TSC Field Personnel Signature

  Sign

• Date and Time

  Date

Client

• Client Representative Name

• Client Representative Title

• Client Representative Email

• Client Representative Signature

  Sign

• Date and Time

  Date