EMS QA/QI Case Review Summary

Incident/ePCR #: [Incident or ePCR identifier]
Event Date: [YYYY-MM-DD / Pending]
Agency/Unit: [Agency name or code; Unit designation]
Response Level: [BLS / ALS]
Crew: [Crew roles and certifications] (Do not include names unless organizational policy requires.)
Review Trigger: [routine audit / complaint / sentinel event / protocol variance / chart deficiency / other]
Reviewer: [Reviewer role/title or initials per policy]
Review Date: [YYYY-MM-DD]

QA/QI Confidentiality Statement

This document is prepared solely for internal quality assurance and improvement activities under the authority of the EMS Medical Director and QA/QI committee. It is not intended to amend, replace, or otherwise alter the original ePCR and should be treated as confidential peer review material with distribution limited per organizational policy. Include only minimum necessary patient identifiers required for QA/QI purposes.

Case Summary

Documented Facts: [Dispatch complaint; high-level clinical course; patient disposition including destination if transported; sources reviewed and their availability] (Use objective, non-judgmental language. Include only information supported by reviewed sources.)

Interpretation/Context: [Synthesis of how documentation and data align; themes, patterns, or potential system issues identified] (Clearly separate interpretations from documented facts.)

Key Findings:

• [Key finding or concern #1]
• [Key finding or concern #2]
• [Key finding or concern #3]
• [Additional findings as applicable]

Timeline

(For each timestamp, indicate the source. If times conflict, display both values and note which is used for metrics per policy. Use "Unavailable" if missing.)

Time	Event	Source
[HH:MM:SS / Unavailable]	Dispatch notified	[CAD / ePCR / Other] (Note discrepancy if applicable)
[HH:MM:SS / Unavailable]	Unit en route	[CAD / ePCR / Other]
[HH:MM:SS / Unavailable]	Arrived scene	[CAD / ePCR / Other]
[HH:MM:SS / Unavailable]	Patient contact	[ePCR / Other]
[HH:MM:SS / Unavailable]	Depart scene	[ePCR / Monitor / Other]
[HH:MM:SS / Unavailable]	Arrive destination	[ePCR / CAD / Other]
[HH:MM:SS / Unavailable]	Transfer of care	[ePCR / Facility documentation / Other]
[Calculated]	Response time	[Calculated per policy]
[Calculated]	Scene time	[Calculated]
[Calculated]	Transport time	[Calculated]

Findings & Opportunities

(Use objective, non-punitive language. Do not infer that undocumented care did not occur—classify documentation gaps appropriately.)

Protocol adherence

• [Protocol name/number] — Expected: [expected action] vs Observed: [documented action]; Rationale documented: [yes / no / partial]; Medical control consulted: [yes / no / N/A]
• [Additional protocol items as needed]

Documentation quality

• [Care likely occurred but not documented / Care unclear / Sources conflicting] — [Description and basis]
• [Additional items as applicable]

Safety concerns

• [Time-sensitive recognition / Medication safety / Airway-monitoring / Communication-handoff / Other] — [Description]
• [Additional concerns as applicable]

Commendations

• [Area of excellence] — [Brief description with supporting source]

Action Items & Closure

(Prioritize by patient safety impact. Use "Pending" rather than leaving fields blank.)

Finding addressed	Specific action	Owner	Due date	Verification method
[Reference to finding]	[Action: coaching / training / protocol clarification / process change]	[Role per policy]	[YYYY-MM-DD / Pending]	[Audit / Training roster / Competency check / Other]
[Additional rows as needed]

Provider feedback: [Summary of feedback provided or planned; date and modality] (Use supportive, non-punitive framing.)

Case status: [open / closed] (If open, note pending items and next review date.)

Escalation pathway: [none / medical director review / risk management / regulatory reporting]

Reviewer attestation: I attest this review was conducted for QA/QI purposes in accordance with organizational policy. [Reviewer name/title per policy] [Date]