CPR Transport Decision

This form is intended to assist NTRAC in developing CPR transport protocols.  Please fill out this form completely after each decision to transport a patient to the hospital or call death on scene following a cardiac arrest.  Do not place any protected health information on this form.  This information will be kept secure and used for process improvement and data collection only.

Q1
Q2
Q3Age of Patient
Q4Code Witnessed
 
 
Q5
Q6Reason for cardiac arrest
Q7If trauma

Treatment Prior To Arrival

Q8Signs and symptoms incompatible with life
Q9CPR
Q10If yes, who iniated CPR
Q11AED
Q12Shock advised
Q13Medication
Q14Lucas Device
Q15

Level of Care

Q16Level of care

Transport Decision

Q17Patient transported
Q18If yes, reason for transport
 
 
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