CPAP PROGRAM DATA RECORD
AMBULANCE SERVICE PROVIDER:
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LEVEL OF PROVIDER:
ALS
BLS
1.
PATIENT INFO:
AGE:
SEX:
MALE
FEMALE
DATE OF SERVICE:
2.
INCLUSION CRITERIA:
Yes
No
a. Retractions or accessory muscle use
b. Respiratory Rate > 25/min
c. Pulse Ox (SpO2) < 94%
3.
SUSPECTED INDICATION
FOR CPAP USE:
CHF
ASTHMA/COPD
PNUEMONIA
UNSURE
4.
VITAL SIGNS:
HR
RR
BP
SpO2
RDS*
LOC
MEDs Administered
A
V
P
U
INITIAL
-
0
1
2
3
4
5
6
7
8
9
10
5 Minutes
-
0
1
2
3
4
5
6
7
8
9
10
10 Minutes
-
0
1
2
3
4
5
6
7
8
9
10
15 Minutes
-
0
1
2
3
4
5
6
7
8
9
10
20 Minutes
-
0
1
2
3
4
5
6
7
8
9
10
25 Minutes
-
0
1
2
3
4
5
6
7
8
9
10
30 Minutes
-
0
1
2
3
4
5
6
7
8
9
10
35 Minutes
-
0
1
2
3
4
5
6
7
8
9
10
40 Minutes
-
0
1
2
3
4
5
6
7
8
9
10
45 Minutes
-
0
1
2
3
4
5
6
7
8
9
10
HOSPITAL
-
0
1
2
3
4
5
6
7
8
9
10
*RDS= RESPIRATORY DISTRESS SCALE 0>10 (10 being the worst)
5.
EMT PERCEPTION OF PT CONDITION UPON ED ARRIVAL:
IMPROVED
SAME
WORSE
6.
PROCEDURAL COMPLICATIONS / TECHNICAL DIFFICULTIES:
7.
CPAP DISCONTINUED PRIOR TO ED ARRIVAL:
YES
NO IF YES, WHY?:
8.
ALS INTERCEPT?
YES
NO IF YES, WHICH ALS UNIT?:
9.
REPLACEMENT CIRCUIT:
Select the type
Boussignac
Flow Safe
Portovent
Whisper Flow