Policy Text
APPENDIX 4.24 -C (Revised 3/16/18)
AED POST INCIDENT REPORT
Patient’s last name
Patient’s f irst name Patient’s address
Phone number
City State Zip
SEX: Male Female
AED o perator:
Incident d ate:
Assistant:
Location:
Assistant:
Estimated time from patient’s collapse until CPR
begun:
Estimated total time of CPR until application of AED:
Was cardiac arrest witnessed?
Yes No Unknown By whom:
Time:
Was CPR started?
Yes No By whom:
Time:
Did the patient ever regain a pulse? Time:
Did the patient begin breathing? Time:
Did the patient ever regain
consciousness?
Time: Hospital patient taken to: Time:
Other treatment:
Transporting a gency:
Comment s/concerns:
Report completed by: Date:
Physician review/r ecommendations:
COORDINATOR REVIEWED:
DATE: REVIEWED WITH RESPONDERS: DATE:
PHYSICIAN REVIEWED:
DATE: COMMENTS: