ALM DRILL RECORD FORM

Welcome to the Drill Documentation Builder!

Our goal is to help you document required drills in a clear, consistent, and survey-ready way.

This tool is designed to guide you through documenting drills based on the type conducted, the scenario exercised, and the activities observed.
Sections will automatically appear or hide based on the type of drill.

How to use this form:

Enter the date of the drill. If the drill is being used to meet a quarterly requirement, be sure to identify the applicable quarter.
Select the type of drill conducted.
Complete the scenario section by briefly describing the event that occurred and what triggered the drill.
Identify the response plan used based on the scenario.
Use the checkboxes to indicate activities observed.
Complete the evaluation section to document observations and any opportunities for improvement.

Helpful tips:

Entries should reflect what occurred during the drill and avoid step-by-step narration.
Leave sections blank if they do not apply so they will not appear in your final report.

After submission:

A copy of your completed drill record will be emailed to the address provided.
Use the report as part of your facility’s drill documentation.
Need to make edits? Your email will contain a link to come back to your report. You will receive a new report after re-submission.
If needed improvements are identified, be sure to coordinate with your facility's Quality program.
Attach any supporting materials as needed (e.g., sign-in sheets, notes).

Questions?

If you need assistance or have questions, you may save your progress and contact support@almss.com.

Facility Name:*

Please enter your access code to access the form:*

If you do not have an access code, please contact support at 770-325-0140, for assistance.** Please note: passcode is case-sensitive **

Conducted/Initiated By (name and title):*

First NameLast NameTitle/Role

Date:*

Date drill occurred

Is this drill being used to meet a quarterly drill requirement?

YesNo

If yes, identify the quarter:

Q1 (Jan–Mar)Q2 (Apr–Jun)Q3 (Jul–Sep)Q4 (Oct–Dec)

Type:*

Select the type of drill conducted. The form will then display only the sections that apply to that drill.

Location:*

Enter the specific area where the scenario occurred (e.g., Waiting Area, PACU, Procedure Room 2).

Participants (choose one):

Enter the List Attendees belowSeparate List/Sign-in sheet attached to report

List of Participants:

List the names of all individuals who participated in the drill.

Attach List/Sign-in sheet

Fire Drill:

Scenario: A scenario is the event that occurred and triggered the drill — it shouldn’t include actions taken, only what happened.

Use the space below to driefly describe an event that occurred and where it took place. The scenario should reflect a situation that could reasonably occur in your facility and explain what triggered the emergency response. One to two sentences is sufficient.

Example scenarios may include (feel free to copy/paste and edit as needed to align with your setting and patient population):

The receptionist noticed that smoke was coming from the trash can in the public restroom near the waiting area during normal operating hours.

Patient Emergency/Code Drill:

Scenario: A scenario is the event that occurred and triggered the drill — it shouldn’t include actions taken, only what happened.

Use the space below to driefly describe an event that occurred and where it took place. The scenario should reflect a situation that could reasonably occur in your facility and explain what triggered the emergency response. One to two sentences is sufficient.

Example scenarios may include (feel free to copy/paste and edit as needed to align with your setting and patient population):

As the procedure was coming to a close, the patient began exhibiting signs of respiratory distress, including decreased oxygen saturation.

Malignant Hyperthermia Drill:

Scenario: A scenario is the event that occurred and triggered the drill — it shouldn’t include actions taken, only what happened.

Use the space below to driefly describe an event that occurred and where it took place. The scenario should reflect a situation that could reasonably occur in your facility and explain what triggered the emergency response. One to two sentences is sufficient.

Example scenarios may include (feel free to copy/paste and edit as needed to align with your setting and patient population):

Mid-procedure, the patient developed muscle rigidity and a rapid rise in end-tidal CO₂, raising concern for malignant hyperthermia.

Emergency (other than fire) Drill:

Scenario: A scenario is the event that occurred and triggered the drill — it shouldn’t include actions taken, only what happened.

Use the space below to driefly describe an event that occurred and where it took place. The scenario should reflect a situation that could reasonably occur in your facility and explain what triggered the emergency response. One to two sentences is sufficient.

Example scenarios may include (feel free to copy/paste and edit as needed to align with your setting and patient population):

A tornado warning was issued for the surrounding area while patients and staff were present in the facility. The facility sustained damages from the tornado.

Scenario:*

General Drill Indicators:*

	YES	NO	N/A
Staff were notified of the drill
Emergency response requested (911), if applicable
Initial response started within appropriate timeframe
Leadership provided direction; staff acknowledged communication
Appropriate response plan was initiated

Description of Response Plan:*

Based on the scenario, identify which response plan was used during the drill. This should reflect the type of response selected, not a step-by-step description of actions. Focus on which response pathway was chosen, not how it was carried out. Examples may include shelter-in-place, evacuation, patient transfer, or an internal clinical response.

Was Evacuation included in the Response Plan?*

YesNo

Fire - Simulated duties carried out as follows:

	YES	NO	N/A
Exit signage illuminated and visible
Egress routes were clear and accessible
Fire extinguisher(s) located for response
Staff responded appropriately and followed direction

Coordinate with the fire alarm company to test the system (can be at a different time than the simulated drill).

Alarm system test was conducted and all in working orderAlarm system test was conducted and not in working order

Actions taken to correct any identified problems:

Patient Emergency/Code - Simulated duties carried out as follows:

	YES	NO	N/A
Emergency/code cart obtained and accessible
Equipment available and ready for use
Appropriately trained staff responded (min of 2 ACLS certified)
Required documentation initiated (e.g., code record, transfer form)
Staff responded appropriately and followed direction
Transfer plan initiated and communicated

MH - Simulated duties carried out as follows:

	YES	NO	N/A
MH cart available and accessible
Dantrolene supply verified
MH protocol available to staff
Assigned roles identified during response
Staff responded appropriately and followed direction
Transfer plan initiated and communicated
Required documentation initiated

Facility Emergency - Simulated duties carried out as follows:

	YES	NO	N/A
Emergency alert/notification received and acknowledged
Leadership assessed potential facility impact
Staff and patients were informed as appropriate
Shelter-in-place or relocation considerations initiated
Facility access and security measures addressed
Patient care areas were assessed for safety
Utilities and critical systems status evaluated (power, backup systems, water, medical gas, IT)
Coordination with external resources occurred, if applicable
Staff responded appropriately and followed direction

Evacuation – Simulated Actions Completed

	YES	NO	N/A
Decision to evacuate was identified and communicated
Evacuation routes were identified and referenced
Designated assembly area(s) were identified
Staff, patients, physicians, and visitors were accounted for
Patient movement and prioritization were simulated (ambulatory and non-ambulatory)
Patients requiring assistance or special considerations were identified
Transportation or patient transfer needs were addressed (if applicable)
External agency coordination was discussed (e.g., EMS, receiving facility), if applicable
All-clear, re-entry, or next steps were discussed
Evacuation roles and responsibilities were reviewed
Leadership oversight during evacuation was simulated

Other Drill Activities:

Be sure to include any other actions that took place that were not addressed above

Response Evaluation:*

Use this section to describe and evaluate the response observed during the drill. Describe what you observed — focus on actions, timing, communication. Consider timeliness, communication, adherence to the chosen plan, equipment readiness, and staff coordination. Document any gaps or opportunities for improvement you observed. Avoid opinions — document what occurred.

Select the option that best reflects the overall staff response outcome:*

All staff responded appropriatelyResponse was generally appropriate with minor opportunities for improvementImprovements needed and follow-up required

Staff: Actions taken to correct identified problems/issues/concerns:

Select the option that best reflects the overall equipment readiness:*

All applicable equipment available, easily accessible, and sufficient for population servedApplicable equipment was generally available with minor opportunities for improvementImprovements needed and follow-up required

Equipment: Actions taken to correct identified problems/issues/concerns:

Comments:

Name of Person Completing this Report:*

First NameLast Name

Email address for report delivery:*

Confirmation Emailexample@example.com

Signature*

DRILL RECORD FORM

Welcome to the Drill Documentation Builder!

Our goal is to help you document required drills in a clear, consistent, and survey-ready way.

How to use this form:

Helpful tips:

After submission:

Questions?

Drill Details

Fire Drill:

Patient Emergency/Code Drill:

Malignant Hyperthermia Drill:

Emergency (other than fire) Drill:

Drill Activities

Drill Outcome and Evaluation

Acknowledgement