/depts/,/depts/uwhealth/,/depts/uwhealth/ambulatory-education/,/depts/uwhealth/ambulatory-education/ambulatory-emergency/,/depts/uwhealth/ambulatory-education/ambulatory-emergency/resources/,

/depts/uwhealth/ambulatory-education/ambulatory-emergency/resources/URGENT-CART-UW-Health-Emergency-Response-Cart-Audit.pdf

201712353

page

100

UWHC,UWMF,

Learning and Development,

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

Urgent Care Cart Audit

Urgent Care Cart Audit - Departments & Programs, UW Health, Ambulatory Education, Ambulatory Emergency, Resources


Clinics BLS Audit 2017 UWH# 4004139 04 20 2017

UW Health Emergency Response Cart Audit (BLS) Clinic: Month/Year:
Urgent Care *keep on file for 3 years


Daily
checks

Cart Lock
Cart lock #
Intact

Oxygen Cylinder
FULL

Present on cart:
CPR Board.
PPE (mask/gloves)
Binder
Needle box

Suction Machine
Clean & ready for use
Green Battery Charge light on
Always plugged in when not in use.

Defib.
Daily test
completed

Enter a √ here
and document
on back page if
any action was
needed.

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Manager or Designee – Monthly Review Signature________________________________________
Monthly Checks: Suction Machine:
AED/defibrillator Battery expiration date _______________ Unplug and run for one (1) minute to make sure battery is holding charge _____
AED/defibrillator Adult Pads expiration date ________________ Suction Machine PM Sticker date __________________
AED/defibrillator Ped Pads expiration date ________________
Monthly checks completed by: Date: _______________
Every February and August: Clinic staff checks cart supplies and expiration dates on all items. Replace items expiring in less than 6 months.
Replace canister every 5 years or as needed (label canister with open date)
February Date Completed by:
August Date Completed by:
Pharmacy -- Bi-annual Medication Tray exchange Additional Medication Tray exchange
February check ________ Expiration Date ___________ Signature __________ Additional check ______ Expiration date _______ Signature ____________
August check ________ Expiration Date ___________ Signature __________ Additional check ______ Expiration date _______ Signature ____________

Clinics BLS Audit 2017 UWH# 4004139 04 20 2017

Date Time Action Taken Signature



































Manager’s Corrective Action Plan (in needed) __________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________