Attachment_12.doc

Public Access Defibrillation Q.I. Report Name of PAD Provider Organization:

Date of Incident:

Time of Incident:

AM/PM

Patient’s Age:

Patient’s Sex: ( ) Male ( ) Female

CPR prior to defibrillation:

( ) Attempted

( ) Not Attempted

Cardiac Arrest: ( ) Not Witnessed ( ) Witnessed by bystander ( ) Witnessed by AED User

Estimated time (in minutes) from arrest to:

CPR

Shock: Indicated/Not Indicated

Estimated time (in minutes) from arrest to 1st shock:

Number of shocks

Additional Comments:

Patient Outcome at incident site:

( ) Return of pulse and breathing

( ) No return of pulse and breathing

( ) Return of pulse with no breathing ( ) Became responsive

( ) Return of pulse, then loss of pulse ( ) Remained unresponsive

Patient Outcome at hospital:

( ) Survived ( ) Expired ( ) Unknown

Name of AED Operator:

Transporting Ambulance:

Name of Facility patient transported to:

Name of Emergency Health Care Provider:

Signature of Emergency Health Care Provider:

This report is to be completed by the AED User and/or the Emergency Health Care Provider within 5 business days of use of an AED.