CMH Ambulance Daily Checklist
Use this form at the beginning of your shift to check the supplies on your ambulance. If you are working on the last day of the month or the first day of the month be sure to do your drug and expired items check.
Permanent link to this form: http://www.ozarksems.com/truck-check.php.

Current protocols are found here: http://www.ozarksems.com/cmh-ems-protocols.pdf. List of medications on ambulances is found in section 7-001 and list of equipment on ambulances is found in section 8-001.
Ambulance Number *
Medic or Squad? *
Crew Assignment *
Date *
MM
/
DD
/
YYYY
Time *
Time
:
Crew Member 1 *
Crew Member 2 *
Crew Member 3
Patient Compartment Essentials
Assure that these essential items are on your ambulance at the beginning of your shift.
Narcotic Box *
RSI Bag *
Lifepak Monitor *
Stock list is found on top of the monitor by the handle and in the ambulance stock list binder.
Main Oxygen PSI *
Big Bag *
If a section is not tagged then review laminated content list found the backpack slip area just below the shoulder straps. Content locations will be specific to each bag. and areas should be labeled. Content list of each flap will be found in the mesh of each flap.
Tagged
Not Tagged
Top Flap
Left Side
Right Side
Middle Upper
Middle Lower
Pediatric Bag *
If the pediatric bag is not tagged then review the inventory list inside the bag and restock appropriately.
Oxygen Bag PSI *
Oxygen Bag Tagged *
Review oxygen contents list and restock as necessary.
Portable Suction Unit *
Yes
No
Present and Clean
Turns on
Charging or has spare battery in unit
Cot *
Yes
No
Present
All Straps attached and clean
Mattress made
Pillow
Blanket
Sheet
Accucheck Glucometer *
Assure that the glucometer is checked at the beginning of your shift. The glucometer should be quality control checked with solution 1 and solution 2 every 12 hours on every ambulance that is in service.
Yes
No
Charging
Minimum 6 strips after QC testing
Minimum 6 lancets
Minimum 6 alcohol prep pads
Minimum 6 bandaids
Computer *
Yes
No
Present
Charging
Patient Compartment - Tower
IV Tray Stocked *
Ensure the IV tray is stocked to the list on the IV tray. Stock list is also found in the ambulance stock list binder.
Red Medication Pack *
Stock list found inside zipper mesh area.
Medication Box *
Review list in lid of medication box for current list
Tower Medications *
Yes
NO
Lidocaine Drip Kit
Nitro Drip Kit
Dopamine Drip Kit
250ml NS
D10 250ml
Normal Saline 1,000ml X6
Lactated Ringers 1,000ml X2
Tower Items *
Yes
No
SPO2/CO2 monitor charging
Disposable SPO2 finger probe
Blood Tubing
Fluid warmer on
Yellow-Top Bleach Wipes
Grey-Top Wipes
Small Bag *
Ensure small bag is tagged and stocked. List is found inside the bag and in the ambulance stock list binder.
Tagged
Not Tagged
Present
Main compartment
Front compartment
Left compartment
Right compartment
Patient Compartment - Other Items
Items *
Yes
No
Pedi-Mate Plus
Protocol Binder
Suction - Action Area
Oxygen Tank X2
IV Pump charging
Extra Cot Battery Charging
Trash Can with 6 trash bags
Sharps Container
Hand Sanitizer
Cabinets
Document which cabinets were tagged and which are not. If a cabinet is not tagged then review the cabinet list for that particular cabinet and restock appropriately.
*
Stocked
Not Stocked
No Cabinet
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Exterior Compartments Items
Ensure these items are on your ambulance, clean, and ready for use.
*
Yes
No
Stair Chair
Surgi-Lift/Bariatric Tarp
Backboards X2
Scoop Stretcher
KED
Adult Traction Splint
Pediatric Traction Splint
DQE Splash Suits
SMR Bag Stocked X2
Life Preserver X2
Lucas II Device
Throw Rope Bag
Cab of Ambulance
Cab Items *
Yes
No
Ambulance Bay Door Opener
CMH ER Opener
Down Time Forms
PCS Forms
ERG
Flashlight
Gloves - All Sizes
Cedar County Map
Dallas County Map
Greene County Map
Hickory County Map
Polk County Map
St.Clair County Map
GPS
Hand Sanitizer
MFA Fuel Card
WEX Fuel Card
Triage Kits X2
High-Viz Vests (X2 extra for students)
Exterior Inspection
Check the exterior illumination. Check for damage. Check for problems.
*
Pass
Fail
Headlights
Brake Lights
Turn Signals
Emergency Lights
Emergency Siren
Scene Lights
Windshield Wipers
Washed
Gauges
Fuel Level *
Mileage *
Comments/Problems/Needs
This is not a tattletale box. This allows us to make our service better by making corrections and always being ready for every emergency. Take PRIDE in your job.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy