Policy 8310F3 - Automated External Defibrillators

Automated External Defibrillators

RISE Charter School

AUTOMATED EXTERNAL DEFIBRILLATOR (AED)

INCIDENT REPORT

 

Date of Incident:                                                                     Time of Incident:                               

 

 

Location of Incident (which building, where in building, etc.):                                                       

                                                                                                                                                           

 

 

Patient’s Age:                                     Patient’s Gender:                     Male               Female

 

 

CPR prior to defibrillation:                              Attempted                               Not Attempted

 

 

Cardiac Arrest:                         Not Witnessed                        Witnessed by Bystander           

                                                  Witnessed by AED team member

 

 

Estimated time (in minutes) from arrest to CPR:                                          

Shock:                                       Indicated                     Not Indicated                       

Estimated time (in minutes) from arrest to 1st AED shock:                                      

Number of shocks:                 

Additional Comments:                                                                                                                      

                                                                                                                                                           

Patient Outcome at Incident Site: 

            _____ Return of pulse and breathing          _____ No return of pulse or breathing

            _____ Return of pulse with no breathing       _____ Became responsive

            _____ Return of pulse, then loss of pulse      _____  Remained unresponsive

 

Name of AED Operator:                                                                                                        

Transporting Ambulance:                                                                                                      

Name of Facility Patient was Transported to:                                                                       

Name of Emergency Health Care Provider:                                                                          

 

                                                                                                                                               

Signature of Health Care Provider                                         Date of Report

 

This report is to be completed by the Emergency Health Care Provider or AED User within 5 business days of use of an AED. 

 

The completed report must be mailed/ret