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IMPLEMENTATION OF DISASTER PLAN

REVIEW SHEET

Disaster Plan implemented by:________________________________________ 

Date of implementation:______________________ 

Reason of implementation: ____________________________________________________________________________________________

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

Was this an internal disaster? ______YES ______NO

Was this an external disaster? ______YES ______NO

Was disaster callbac initiated? ______YES ______NO

!y "hom? _____________________________________________________________ 

#ype of disaster: $Specify% _________________________________________________ 

!riefly& b't completely describe the e(ents s'rro'ndin) the disaster:

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

Were comm'nications ade*'ate? ___YES ___

Did +hief of Staff place physicians in needed areas? ___YES ___

Were any (ictims or patients transferred? ___YES ___

,o" many? ___________Why?_____________________________________________________ 

Were area hospitals notified of the disaster and prepared to help? ___YES ___

Was the fire department a(ailable? ___YES ___

Was the police department a(ailable? ___YES ___

What comm'nity a)encies "ere in(ol(ed?

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

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IMPLEMENTATION OF DISASTER PLAN

REVIEW SHEET

Were hospital patients assessed for dischar)e if beds "ere needed for disaster (ictims? ___YES___

,o" many patients "ere in the hospital at the time of implementation of the disaster plan? _______________ 

,o" many (isitors "ere in the hospital at the time of implementation of the disaster plan? ________________ 

,o" "ere the departments staffed?

DEPARTMENT ON DUTY CALLED IN TOTAL ADEQUATE

 /dministration _______ _______ ______ ______ 

!'siness Office _______ _______ ______ ______  

P'rchasin) _______ _______ ______ ______  

Dietary _______ _______ ______ ______  

Pharmacy _______ _______ ______ ______  

0aintenance _______ _______ ______ ______  

,o'seeepin) _______ _______ ______ ______  

Radiolo)y _______ _______ ______ ______  

1aboratory _______ _______ ______ ______  

Respiratory _______ _______ ______ ______  

Physical #herapy _______ _______ ______ ______  

0edical Records _______ _______ ______ ______  

N'rsin) _______ _______ ______ ______  

Operatin) Room _______ _______ ______ ______  

+entral Ser(ice _______ _______ ______ ______  

Reco(ery room _______ _______ ______ ______  

0edical Staff _______ _______ ______ ______  

2f there "ere other cate)ories of indi(id'als in the hospital at the time of implementation of the disaster plan& please the cate)ory $e3)3& constr'ction "orers& etc3%:

+/#E4OR2ES: N50!ER: ________________________________________ ______________________________________ 

 ________________________________________ ______________________________________ 

 ________________________________________ ______________________________________ 

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IMPLEMENTATION OF DISASTER PLAN

REVIEW SHEET

Was hospital protocol follo"ed? ___YES___

Did staff respond accordin) to protocol? ___YES ___

Did s'per(isory personnel respond accordin) to protocol? ___YES ___

Please explain any ne)ati(e ans"ers:

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

,o" lon) did it tae staff to respond once the disaster plan "as implemented?________________________ 

,o" lon) did it tae for s'per(isory personnel to respond once the disaster plan "as implemented?_____________

Were problems enco'ntered "ith patients& (isitors& or other indi(id'als "hile the disaster plan "as in effect?

 ___YES ____NO

Please explain problem areas:

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

Was correcti(e action taen at the time the problem$s% "ere identified? ___YES ___

Explain the correcti(e action:

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

2s there a need for f't're correcti(e action? ___YES ___

Explain:

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

 ____________________________________________________________________________________________

O(erall implementation& response& and process of the disaster plan "as:

Excellent________ 4ood ________ 7air________ Poor________ 

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