Roaring Fork Fire Rescue Authority EMS QM Program Case ReviewRating (required)Exceptional CareInsufficient DocumentationNo Adverse OutcomeMajor Adverse OutcomeAppropriate CarePoor CommunicationMinor Adverse OutcomeSystems Issue IdentifiedIncident Number (required)Indication for Review (required)DeathNon-compliance with guidline /protocolCharting deficiencyFull Trauma Activation Criteria MetTrauma Under-ActivationAbnormal EKG TransmissionsStroke SymptomsAll Waivered ACTHospital or Agency Request for ReviewProvider or Authority RequestPatient DOB (required)Station Number (required)Crew Involved (required)Date of Incident (required)Call Request Dx (required)EmergentNon-EmergentTransport Dx (required)EmergentNon-EmergentNo TransportDispatched (required)Arrived (required)Transport (required)Arrival (required)Destination (required)AVHVVHRefusalNo TransportScene Address (required)City (required)State (required)Zip Code (required)Patient chief complaint and history documented appropriately? (required)YesNoDetailsPatient Assessment and impressions documented appropriately? (required)YesNoDetailsCardiac arrest documented appropriately? (required)YesNoDetailsVital signs documented and ECG uploaded appropriately? (required)YesNoDetailsInterventions prioritized appropriately and administered per protocol? (required)YesNoDetailsTrauma level identifited appropriately (required)YesNoN/ADetailsNarrative includes adequte information? (required)YesNoDetailsProvider IssueSystem IssueLoop Closure (required)Officer Reviewing ePCR First and Last Name (required)Email (required)Your Signature (required)Confirm e-SignatureReview Electronic Records and Signatures Policy (required)Read our Electronic Record and Signature Disclosure I agree to use electronic records and signaturesThere was a problem saving your submission. Please try again later.Please wait while your submission is being saved...Submitting...SubmitThank you, your submission has been received.
