Medical Incident Review Form

Medical Incident Review Form (MIR)

The purpose of this referral is to improve the quality and efficiency of patient care in the Peninsulas Emergency Medical Service Council, Inc. region. This form is intended to relay comments on any incident, positive or negative, regarding provision of EMS in the region. Submission of this document triggers further review of the specific incident. All information obtained through this process will remain confidential. This information will be used by the EMS agency and it’s Operational Medical Director (OMD) for the purposes of Quality Improvement (QI) to result in improved patient care.

Please provide as much of the requested information as possible. Some fields are mandatory.

All MIR information is confidential.

Section 1: Referrer Contact Information

Name:*

First

Last

Agency:

Date:*

Phone Number:

E-mail:*

Section 2: Incident Details

Time:*

AM/PM

Call/PPCR Number:

Agency Involved:

AIC (If known):

Select:*

Receiving Facility:*

Receiving Physician:

Section 3: Reason for Review

Checkbox:*

Unable to establish contact with Medical Control

Medical Control treatment needed but not performed

Medical control treatment initiated without physician order

Regarding treatment orders form on-line Medical Control physician

Regarding hospital diversion of patient

Regarding EMS treatment or actions

Other - please describe below

Other:

Section 4: Description of Events

Description:*

Section 5: Supporting Files

PPCR:

Document 1:

Document 2:

Document 3:

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