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/depts/uwhealth/ambulatory-education/ambulatory-emergency/resources/Debrief-Checklist-template.pdf

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Learning and Development,

Departments & Programs,UW Health,Ambulatory Education,Ambulatory Emergency,Resources

Debrief Checklist Template

Debrief Checklist Template - Departments & Programs, UW Health, Ambulatory Education, Ambulatory Emergency, Resources




UW Health Ambulatory Debriefing Summary
This form is to be used after an emergency event that would benefit from debriefing
- Medical Response: encouraged for continuous performance improvement
- Code Blue: highly encouraged for continuous performance improvement

Directions:
- RN Manager/RN Supervisor or Coordinator should lead debrief
- Preferably same day as event or as soon as possible
- Include only staff involved in event

Attendance
Name/Role: Name/Role:






Debrief
Date/Time of Event

Location/Department of Event

RN Manager/RN Supervisor or
Coordinator leading the debrief

Short summary of event/Event
description








List any issues during the event with
equipment?





List any issues during the event with
following proper procedures?









List any issues during the event with
performance of staff?






Recognition of things that went well
during the event






Concerns discussed surrounding the
event/things that could have gone
better?






Recommendations/needs prior to
future event







Is there a need for assistance/education
from Ambulatory Educators? Please
Specify









ATTACH THIS DOCUMENT TO PSN

Send or email a copy of this form to Ambulatory Educators at Mail Code 1035 or
Staff.Educators@uwmf.wisc.edu