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Performance
Clinical Review Request
This form is used to report clinical incidents to the Performance Improvement Committee.
This report will be sent to the PI Committee members only.
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Greenwich Mean Time (UTC)
Person Reporting
Required
Department or Agency
Crew Member 1
Crew Member 2
Student / Rider
Others present:
Date and Time of Incident
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Call or Incident Number
Category
Required
Medication Issue (Under or Overdose)
Treatment Decision Question (Did I do the right this? Should I have done more?)
Acting Outside of Protocols (I did the right thing for the patient and got , or did not get medical direction)
Destination Decision
Hospital Staff Interactions
Location of Incident
Required
Description of Incident
Required
Email of person reporting
Required
Submit