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Medical Interventions Form
Medical Interventions Form
Officer Name
*
First
Last
Date of Incident
*
Date Format: MM slash DD slash YYYY
Shift
A
B
C
Incident Number
*
PPE
Type of PPE used in Patient Contact/Care
Standard PPE
Increased PPE
Gowns used from:
MCHD
MCESD4
Intervention Performed / Items Used
AED
CPR
Breathing Treatment - albuterol
i-gel
EZ Cap Colorimetric
Tourniquet
Combat Gauze
Epi
Oral Glucose
ASA
Viral Filter
Was EMS present during intervention performed?
Yes
No
Were supplies restocked from the medic unit?
Yes
No
Additional Notes
Please List All Personnel who had contact with patient
