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<br />1,-,1--t0as TIIM~-------0 lnmlctlon glftr1 0 i..tt WO lostructlont O AW
<br />.~med type: _________________ _
<br />Mode~ll'lnll>«t-------------------
<br />Tranllwto ----Br-0 RH ' 0 AClS O BI.S □ll-.lll)Ottation t!nw ____ _
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<br />• .:>··-~ ,//~,\.1._'1-,,;\~ ;l ~\ :\ ... :·
<br />Reportcaled '°-------..--,,=-r---rme _______ _
<br />\11'.a.nt pn,pe,ty t
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<br />--.,.\""T,, qo-=t4
<br />EDHU/0BS Start time __ _ Stop time ----
<br />N,11.S -,, ,,.., :., -JY,": ~ : __ " .... :L'-,. ...
<br />Redio-MICN EMS Qare r ~l V\---£KG 11!'Monttor n 12 lead nuA
<br />Cardlo=lorv'defib n external n Internal Pel1cardlocentesls v Bladder Irrigation X
<br />Conscious sedation ThlOOlbolyals, IV; O Irrigation ftuld ml
<br />CPR □Code Cart &•nneuro
<br />Pacer (external) transc1.rt cath/electnxle placement ·.
<br />Pacer llt,l,wnalj ln!mven calh/elecirode ~ .
<br />Foley lnsenlon:
<br />size type
<br />AIJINl,.Y.UPNR -' ' RA,..,,.,_mask -Slralaht calhet&1 Ins ertion x
<br />Crico~ ,l\,uu,ny'.., --r ,r1 '-~ I.Iii i..lj End-lldal CO2 x .:. •·· "' ~ .. ,
<br />lntobatlon, ET .:..:...J;.ii ~ fp{_:___ sta--~ Nasa!,1rach suction v Eve exam
<br />□mx ONTx 1n ... 1 .. oMVV1 ic Flouresceln lamo orocedure
<br />n LMA x . n Combitutie L-n 8ot.dit t.-o-wi_tnm_hou!J Nasal endoscoov
<br />Trach X Peak floww Nasal packina/caut91V
<br />AIRWAY, t.OWla~ •-~ n.-P\.iseQQYll!tl'l nllhMl'J:ontii Slit lamp proced ure
<br />Bro,..,. 'Y Aa,p{mor/ treatment ✓ ~ ~ c-·~
<br />Chest tube Insertion: 0 Time Out Ventf1atol'. , Amoutetlon of
<br />:~:x ?. slz.e fr, ~
<br />ht X ___:_i__ size fr, I 1'I
<br />G-<:olkr. n Hard n Phil/Serra n ~
<br />'('.,..,,
<br />Laryngoscopy y EWALD aspiratlolvtavage X-.-Crutches n direct D Indirect O ftberoptlc D lnigatlon fluid mL Dislocation w/manlculatlon
<br />Thoracentesis X ml • n Pos n Nea n lndet8!1Tllnate
<br />nTimeOut
<br />,
<br />Gastric aspiration/lavage x_ ~
<br />. Fracture stablllzatlon of
<br />D with msnlpuletlon D WO man~latio!
<br />·T'honltotomy • • • 0 ln19!1tlon ffuld mL lm,mbHlzer to
<br />4-"lAccaa I Gastrottonomy tube )[ Inject, block L--t~
<br />Autl:llnlMfuserx n '" □change Needle asolratlon of ml
<br />8 load/ /blood croducts transfusion X NG M>e Insertion: Needle lnjectlon x to
<br />Catheter Insertion: D Nasal D Q-al Pressure cui,~u•= t (Strvkeo
<br />O MUnex size ,~. size □ Splint □ Other
<br />OCordlsx size Perfloneal lavage X Applled lo
<br />QCutdQwnv slz.e 0 lmgetlon ftuid ml □Traction .tvce. applied to
<br />X size OPos □Neg □1~
<br />W~x SW! -J{ ml
<br />size ·. "}
<br />Steinman cln n1,icemeht
<br />Vtbo.n:I -, -· e~•
<br />PIVCB<WII ,.
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<br />D Saline lock X 8ml BOA 'deive!v!Gare of mother n Triple lumen x size De!IYerY, vaalnaJ
<br />lntraosseous neeQle ~--ml ~ of placen~ Only
<br />Denial of r!Qhts
<br />Leaal hold 5150
<br />1:1x
<br />Lewi.one ftuk:l warmer Newborn care Restraints
<br />~~ Newf>om resuscftatlon
<br />PeMc axamx ~~ •-ESS
<br />Dermabond to size Rectal exam x
<br />Excision of . .. -·: ~.:,.,·
<br />Gelfoam application to slza.__ Btl'n dr1Q O sma1 n med D 1g
<br />Culture x
<br />Tvoe
<br />Glucometer x
<br />I &Dof of
<br />Removal of forem bodv from ... ii§ : '· ........ , :
<br />~ Qntsmed-slm -□Anglo Tllne Suture .. _._ ' r1 CTSCAN -OC-Spme
<br />Repair; plastlc, of -□Doppler -OCXR -5ut1Jr& .. _. ' LJ PeMsXR □MRI
<br />Swgicalto size 0 Treadmill -□Swlmners -~-XR....__ Wound lrrlgatlon to ml
<br />llfMr~ OPos Wound pacidng to with □Neg
<br />Gualac x
<br />Hemocuex
<br />HeaVflnger stick x
<br />Venous bio9d collectlon v .
<br />icP flM o c.mo n U::ox ov <'<OIi,
<br />ICP mo nal" •
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