Medical Record Evaluation Tool
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3Level III Medical Record Evaluation Tool
Time Tracking
Hospital:
EMS
Surgeon
dispatched
Notified
EMS en
Transfer
Reviewer:
route
ordered
EMS arrive
X-ray
Check the items below found in the medical
EMS leave
record.
CT
scene
◄ Denotes audit filter
Team
Lab
activated
Pt arrive
Transferre
hospital
d
ED
Surgeon
Physician
arrive
arrive
Pre-hospital/EMS:
EMS hospital care appropriate?
EMS scene time appropriate per region?
Emergency Department/Initial Resuscitation:
Trauma team activation (TTA) protocol followed? ◄
Level of activation?
Any issues regarding transfer decision?
Physician present at resuscitation within 30 minutes of patient arrival? ◄
Flow sheet used?
General surgeon response time to trauma activation ◄
0
0
1
& 2
surveys immediate and accurate?
ATLS guidelines followed?
Appropriate diagnostic tests ordered (lab, x-ray, CT)?
Vital signs monitored completely and periodically (GCS, BP, HR, Resp., SaO
, temp.)?
2
Fluids monitored?
Balanced resuscitation (blood products)?
Final Level III Medical Record Evaluation.9.22.16
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