CPAP QA Sheet Case Number _____
Medics on the call need to fill this QA sheet out and staple it to the front of the Report QA copy
1. Asses and Record Vitals initial HR _____ RR ______ B/P _______ SaO2 ________
10 min. _____ ______ _______ ________
20 min. _____ ______ _______ ________
2. Assess Pulse Ox at Room Air % at Room Air ______
3. Inclusion Criteria Yes No
a. Retractions or accessory muscle use ______ ______
b. Pulmonary Edema ______ ______
c. Respiratory Rate > 25 / minute ______ ______
d. Pulse Ox < 92% ______ ______
4. Indication for use of CPAP
a. Acute Congested Heart Failure __________
b. Chronic Congested Heart Failure __________
5. Respiratory Difficulty Scale 1 – 10, 10 being the worse initial _________
7. Condition Upon Admission to ED Better _____ Same______ Worse _______
Medic filling out the QA form _________________________________________________
6. Final PEEP setting used _______