Medical Documentation

1.6 There should be a formal case sheet completed at the time of the mission recording relevant demographic, clinical, operational details and record of patient management. A copy should accompany the patient. Another copy must be kept at the service headquarters in a manner consistent with patient confidentiality.

1.6.1 Core information should include:

1.6.2.1 Patient

• Name
  
• Date of Birth
  
• Gender
  
• Medical record number/Ambulance case reference
  

1.6.2.2 Notification

• Time/date
  
• Location/Hospital
  
• Type (Primary/Secondary/Tertiary/Return)
  

1.6.2.3 Problem

• Clinical reason for request
  
• Vital signs (where known)
  

1.6.2.4 Response

• Dispatch time/date
  
• Urgency
  
• Mode (Road/RW/FW/other)
  

1.6.2.5 Patient contact

• Time/date
  
• Vital signs at first look
  
• Interventions
  
• Departure Time/date
  

1.6.2.6 Admission

• Time/date
  
• Location
  
• Vital signs at end of transport
  

1.6.2.7 Outcome

• Medical record number
  
• Discharged from hospital/Died