Western Virginia EMS Council, Inc

Western Virginia EMS Regional PI Form

The purpose of this referral is to improve the quality and efficiency of patient care in the Western Virginia region. This form is intended for positive and negative comments regarding EMS incidents in the Western Virginia region. Submission of this document initiates further review of the specific incident. The intent of this form is to identify "system" issues. All information obtained through this process will remain confidential. This information will be used by the EMS Agency and Operational Medical Director (OMD) for the purposes of Quality Improvement (QI) and Performance Improvement (PI) with the ultimate goal being improved patient care and offer solutions to improve the system as a whole.

This form may be submitted anonymously.

Please select a reason for this referral:

Other Reason:

Your Name:

Your Agency:

Your E-Mail Address:

Agency/Facility Targeted for PI:

EMS Incident #:

Patient Record #:

Receiving Hospital:

Date Received at/by Hospital

Date of Events

Patient (Name):

Patient SSN #:

Patient DOB:

Injury/Diagnosis (In your words):

Description of Events:

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