Emergency Medical Services

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Emergency Medical Services

Director: Jeff Sargent
Naloxone (Narcan) Administration Form
Download a printable copy of this form here.

The purpose of this report is to collect data about the training, implementation, and effectiveness of this addition to the BLS protocols, for continuous quality improvement.

The use of Naloxone (Narcan) by BLS providers in Skagit County to treat life-threatening opioid overdose is optional. However, responders with agencies that choose to carry and use Naloxone are required by the State of Washington to complete the 4 hour training program approved by the MPD and County Training Manager.


For information and FAQs about public use of Naloxone in Washington, please visit http://stopoverdose.org.

* 1. Incident Date:


* 2. Incident (CAD) Number:


* 3. District/Agency AND Station #:


* 4. Name of Provider completing this report:


* 5. Indications for Naloxone use
(choose all that apply)

Suspected opioid overdose
Decreased LOC
Respiratory rate < 6/min
Respiratory arrest
Impending cardiopulmonary arrest
Circulatory shock
Other (please specify)


* 6. Naloxone was first administered by:
Bystander
Law Enforcement
BLS
ALS
Provide additional detail, as appropriate


* 7. In what way(s) did the patient respond to Naloxone administration
(choose all that apply)

patient did not respond/improve following treatment
Improved breathing, eliminating the need for ventilatory assistance
Improved breathing, but still requiring ventilatory assistance
Improved LOC
Signs of withdrawl (agitation, tachycardia, nausea, etc.)
Other (please specify)


* 8. How was the patient transported to the ED?

BLS
ALS
no transport

* 9. Narrative:
(Do not inlcude HIPAA protected information such as name or DOB. Complete this section in order to document the circumstances of the intervention, note any problems, and/or to include other information relevant to data collection for educational, statistical, and quality assurance purposes)